Returning traveler with fever and Malaria prophylaxis

Question 1

Time course for typhoid fever

Answer 1

Week 1: rising fever, bacteremia, relative bradycardia (pulse temp disassociation)

Week 2: abdominal pain, rose spots on trunk and abdomen

Week 3 hepatosplenomegaly and intestinal bleeding and perforation

Question 2

what causes typhoid fever?

Answer 2

samlonella typhi or samonella paratyphi

Seen in the developing world obtained from contaminated food or water

Question 3

what is seen on labs with typhoid fever?

Answer 3

normal platelet count, leukopenia, leukocytosis or abnormal liver function tests.

Question 4

What is the most serious stage of typhoid fever?

Answer 4

intestinal perforation due to hyperproliferation of Peyer’s patches which can lead to peritonitis, bacteremia, septic shock and death

Question 5

how to diagnose typhi fever?

Answer 5

by blood culture but also from stool, urine and intestinal contents. Most sensitive is bone marrow (>90% yield of organisms from other body fluids. Cultures are made out of convenience but sensitivity.

Question 6

Classic dengue fever manifestations

Answer 6

5-7 days incubation and see headache, retro-orbital eye pain, petechial rash

body aches (breakbone fever)

Question 7

Laboratory findings of Dengue fever

Answer 7

leukopenia, thrombocytopenia, elevations in AST and ALT

Question 8

Manifestations of Leptospirosis

Answer 8

See conjunctival suffusion (redness of the conjunctival inflammatory exudates)

abrupt onset of fever, myalgias, headache, and abdominal pain

Question 9

clinical manifestations of malaria

Answer 9

nonspecific symptoms of fever that waxes and wanes, chills, headache, abdominal pain and N/V and

see splenomegaly, anemia thrombocytopenia and hyperbilirubinemia.

NO RASH

Question 10

acute viral hepatitis presentation

Answer 10

fever, abdominal pain, nausea, vomiting, and relative bradycardia. See abdominal pain marked elevations in AST/ALT. >1000 and ALT > AST. See rise in total and direct bilirubin and alkaline phosphatase levels

Question 11

differential diagnosis for traveler returning endemic area with fever

Answer 11

malaria,

yellow fever,

dengue fever,

acute HIV infection,

meningococcal dx,

acute schistosomiasis/Katayama fever,

typhoid fever

Question 12

acute onset febrile illness, scleral icterus, mild splenomegaly, anemia, thrombocytopenia

no rash but jaundiced

Answer 12

malaria

Question 13

diagnosis of malaria

Answer 13

peripheral blood smear looking for trophozoites

Question 14

most common malaria species

Answer 14

plasmodium falciparum plasmodium vivax is second

Question 15

how does malaria cause problems

Answer 15

the infected parasite containing RBCs adhere to nearby vessels causing small infarcts and leakage of capillaries and resulting in organ dysfunction

Question 16

common medications for malaria prophylaxis

Answer 16

cloroquine mefloquine, doxycycline target blood stage of parasite (blood schizonticides when released from liver.

Question 17

tissue schizonticides (life stage targeted by atovaquone/proguanil) are from

Answer 17

liver stage where the parasites grow and can stay dormant in liver and other tissues

Question 18

how long to continue atorvaquone/proquanil

Answer 18

4 weeks after leaving endemic area to ensure eradication of parasites released by liver thus can’t stop doxycycline once you return to US. Need to continue it

Question 19

eosinophilia and someone who returns with fever and had been drinking and swimming in local water

Answer 19

consider schistosomiasis and check stool sample for ova and parasites.

Question 20

nifurtimox is used to treat

Answer 20

Chagas dx (American trypanosomiasis) caused by Trypanosoma cruzi antiparasite drug

Question 21

Mebendazole is used to treat

Answer 21

treats the worms:

ascariasis, trichuriasis, hookworm and pinworm infections

Question 22

atorvaquone-proguanil is liked because

Answer 22

well tolerated

Question 23

how to administer atorvaquone-proguanil for malaria prophylaxis?

Answer 23

taking daily 1-2 days before and to 7 days after returning from trip with exposure to malaria. It’s expensive

Question 24

Mefloquine schedule for malaria prophylaxis contraindication to mefloquine

Answer 24

this is taken weekly contraindicated in neuropsychiatric dx

Question 25

what must be screened prior to use of primaquine?

Answer 25

G5PD deficiency

Question 26

what should pregnant pts who wish to take malaria prophylaxis take?

Answer 26

chloroquine when going to chloroquine sensitive areas

take mefloquine for chloroquine resistant areas

Question 27

how to take doxycycline as prophyalxis for malaria?

Answer 27

taken 30 days after returning to trip with exposure to malaria. IT doesn’t attack malaria liver forms of parasite

Question 28

what are the drawbacks of using doxycycline as prophylaxis for malaria?

Answer 28

it’s can causes photosensitivity and GI upset

Question 29

Chemoprophylaxis for malaria depends on:

Answer 29

plasmodium species (p falciparum or P vivax or P ovale)

Resistance patterns which vary by region.

Question 30

What types of chemoprophylaxis for malaria treatments are there:

Answer 30

3 types of antimalarial drugs:

1. Hepatic schizonticides - attack the liver forms of parasite (atovaquone-proguanil)

2. Hypnozoiticides - attack against the quiescent liver forms of P vivax and P ovale (primaquine)

3. Blood schizonticides - attack blood forms of parasite once released from liver (chloroquine, mefloquine, doxycyline, and atorvaquone-proguanil and primaquine)

Question 31

Chart of malaria prophylaxis

Answer 31

Question 32

What is Dengue fever presentation?

what is it’s time course for illness?

Answer 32

1st part of illness 3-5 days with myalgias and retroorbital pain and headache.

Then they see bleeding complications.

As symptoms improve there is a macular or maculopapular rash (islands of white on a red sea) and then they may develop capillary lead syndrome with edema, effusions and hypotension and shock and severe hemorrhage.

Question 33

how do we know that patient is Dengue’s critical period for complications?

Answer 33

positive tourniquet test which is petechiea after putting on a BP cuff or tourniquet on for 5 minutes over am.

In the hemorrhagic phase: see capillary leakage with edema, effusions, hypotension or shock and severe hemorrhage.

Question 34

Labs seen with Dengue fever

how is Dengue fever diagnosed?

Answer 34

leukopenia, thrombocytopenia and elevated hematocrit due to hemoconcentration even i nthe absence of hemorrhage.

Diagnosis is via serology or direct viral testing for components.

Question 35

How to treat Dengue fever?

Answer 35

Treatment is supportive care.

Question 36

Leptospirosis clinical presentation

Answer 36

slimilar to dengue fever but pts have conjunctival suffusion, pulmonary involvement with cough, dypsnea and renal involvement (proteinuria and electrolyte abnormalities)

from rat poo and Hawaii

Question 37

weeks of sequential fever by development of rose spots (salmon colored macules on trunk and abdomen) and abdominal pain. Can see splenomegaly and sometimes bleeding or shock

Answer 37

this is typhoid fever.

Question 38

dengue fever is from

Answer 38

mosquito transmitted virus

fever returning from endemic area like Caribbean, parts of Asia, and S America.

Develop fever, retroorbital pain and headache and then a macular rash and see bleeding complications and leukopenia and thrombocytopenia ais most common.

Question 39

variation in severity of Dengue virus infection:

Answer 39

can be a self limiting febrile illness to a dengue hemorrhagic fever with shock syndrome

Question 40

Leishmania donovani causes a

Answer 40

visceral leishmaniasis (called kala-azar) which causes insidious onset and progression of fever, malaise, and weight loss and splenomegaly.

seen in East Africa and Indian subcontinent and Europe, north Africa and Latin America.

Testing is done via the latex agglutination test or rK39 immunochromatographic test which will be positive.

Question 41

Dengue virus is

Answer 41

most common mosquito borne illness worldwide

incubation is 3-14 days and febrile illness lasts 5-7 days.

Question 42

Diagnosis of dengue virus

Answer 42

detection of viral RNA via PCR <3 days of illness or IgM immunoassay >3 days illness.

Tests are not widely available. diagnosis is generally clinically and treated supportively with aggressive hydration for plasma leakage and close monitoring.

Question 43

Clinical features and how leptospirosis presents

Answer 43

recent tropical area travel

abrupt onset of systemic symptoms of (fever, myalgias, abdominal pain, muscle pain) and conjunctival suffusion

See hemorrhagic jaundice

caused by zoonotic infection from spirochete Leptospira interrogans which is seen in Hawaii and temperate climates. Infects wild and domestic rodents and these organisms shed it in their urine.

Question 44

leptospirosis severity

remember leptospirosis =/= leishmaniasis don’t get them confused.

Answer 44

can be a mild subclinical to severe infection.

See abrupt onset of systemic and GI symptoms

Physical exam: muscle tenderness, and hepatosplenomegaly

see conjunctival suffusion- redness of the conjunctiva without inflammatory exudates- characteristic of leptospirosis.

Diagnosis is via serological testing or culture of organism from blood, urine, or CSF.

Question 45

Treatment of leptospirosis

Answer 45

treat with doxycycline or penicillin

Question 46

what is the clinical presentation for chikungunya fever?

Answer 46

abrupt onset of persistently high fevers and characteristic severe polyarthralgias “bone break pain” (seen in virtually all cases and involves multiple joint groups)

Some pts have a rash

see lymphopenia and thrombocytopenia and elevated LFTs.

Question 47

diagnosis of chikungunya fever?

Answer 47

serological studies PCR done within the 1st 5 days confirms diagnosis

infection is self limited (resolves in 7-10 days) though some may develop serious complications and rheumatic symptoms can linger. May be treated with methotrexate

Question 48

new onset persistent high fevers after returning from the Dominican Republic. Has multiple severe polyarthralgias and has rash.

sees elevated LFTs, leukopenia and thrombocytopenia.

what is this?

Answer 48

Chikunguyna fever

• transmitted via the aedes mosquito (also transmits ZIka and dengue)

Question 49

Hantavirus is from

Answer 49

causes a hantavirus cardiopulmonary syndrome or hemorrhagic fever with renal syndrome

occurs about 2-3 weeks after exposure.

seen in New Mexico. Transmitted by rodents

Question 50

zika virus is located in

transmitted by

Answer 50

africa, southeast asian and now seen in central and south america

• from mosquito bite and from intrauterine, pernatal maternal fetal spread and sexual transmission from infected male partner.

Question 51

Zika virus presnetation

Answer 51

conjunctivitis, mild illness but some people develop Guillian Barre Syndrome

most complications are seen with pregnant women and their babies

Question 52

birth defects related to ZIKA

Answer 52

microcephaly

severe brain and eye defects

impared growth and fetal loss

Question 53

how to prevent ZIKA virus?

Answer 53

pregnant women avoid traveling to areas where Zika virus is present

• no conception until at least 3 months (for men) or 8 weeks (for women) after last possible ZIka virus exposure or from onset of symptoms or diagnosis.

testing for virus is with PCR of serum or urine. See IgM antibody after 2 weeks.