Returning traveler with fever and Malaria prophylaxis Flashcards
all exotic presentations
Time course for typhoid fever
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
what causes typhoid fever?
samlonella typhi or samonella paratyphi
Seen in the developing world obtained from contaminated food or water
what is seen on labs with typhoid fever?
normal platelet count, leukopenia, leukocytosis or abnormal liver function tests.
What is the most serious stage of typhoid fever?
intestinal perforation due to hyperproliferation of Peyer’s patches which can lead to peritonitis, bacteremia, septic shock and death
how to diagnose typhi fever?
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.
Classic dengue fever manifestations
5-7 days incubation and see headache, retro-orbital eye pain, petechial rash
body aches (breakbone fever)
Laboratory findings of Dengue fever
leukopenia, thrombocytopenia, elevations in AST and ALT
Manifestations of Leptospirosis
See conjunctival suffusion (redness of the conjunctival inflammatory exudates)
abrupt onset of fever, myalgias, headache, and abdominal pain
clinical manifestations of malaria
nonspecific symptoms of fever that waxes and wanes, chills, headache, abdominal pain and N/V and
see splenomegaly, anemia thrombocytopenia and hyperbilirubinemia.
NO RASH
acute viral hepatitis presentation
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
differential diagnosis for traveler returning endemic area with fever
malaria,
yellow fever,
dengue fever,
acute HIV infection,
meningococcal dx,
acute schistosomiasis/Katayama fever,
typhoid fever
acute onset febrile illness, scleral icterus, mild splenomegaly, anemia, thrombocytopenia
no rash but jaundiced
malaria
diagnosis of malaria
peripheral blood smear looking for trophozoites
most common malaria species
plasmodium falciparum plasmodium vivax is second
how does malaria cause problems
the infected parasite containing RBCs adhere to nearby vessels causing small infarcts and leakage of capillaries and resulting in organ dysfunction
common medications for malaria prophylaxis
cloroquine mefloquine, doxycycline target blood stage of parasite (blood schizonticides when released from liver.
tissue schizonticides (life stage targeted by atovaquone/proguanil) are from
liver stage where the parasites grow and can stay dormant in liver and other tissues
how long to continue atorvaquone/proquanil
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
eosinophilia and someone who returns with fever and had been drinking and swimming in local water
consider schistosomiasis and check stool sample for ova and parasites.
nifurtimox is used to treat
Chagas dx (American trypanosomiasis) caused by Trypanosoma cruzi antiparasite drug
Mebendazole is used to treat
treats the worms:
ascariasis, trichuriasis, hookworm and pinworm infections
atorvaquone-proguanil is liked because
well tolerated
how to administer atorvaquone-proguanil for malaria prophylaxis?
taking daily 1-2 days before and to 7 days after returning from trip with exposure to malaria. It’s expensive
Mefloquine schedule for malaria prophylaxis contraindication to mefloquine
this is taken weekly contraindicated in neuropsychiatric dx
what must be screened prior to use of primaquine?
G5PD deficiency
what should pregnant pts who wish to take malaria prophylaxis take?
chloroquine when going to chloroquine sensitive areas
take mefloquine for chloroquine resistant areas
how to take doxycycline as prophyalxis for malaria?
taken 30 days after returning to trip with exposure to malaria. IT doesn’t attack malaria liver forms of parasite
what are the drawbacks of using doxycycline as prophylaxis for malaria?
it’s can causes photosensitivity and GI upset
Chemoprophylaxis for malaria depends on:
plasmodium species (p falciparum or P vivax or P ovale)
Resistance patterns which vary by region.
What types of chemoprophylaxis for malaria treatments are there:
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)
Chart of malaria prophylaxis
What is Dengue fever presentation?
what is it’s time course for illness?
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.
how do we know that patient is Dengue’s critical period for complications?
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.
Labs seen with Dengue fever
how is Dengue fever diagnosed?
leukopenia, thrombocytopenia and elevated hematocrit due to hemoconcentration even i nthe absence of hemorrhage.
Diagnosis is via serology or direct viral testing for components.
How to treat Dengue fever?
Treatment is supportive care.
Leptospirosis clinical presentation
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
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
this is typhoid fever.
dengue fever is from
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.
variation in severity of Dengue virus infection:
can be a self limiting febrile illness to a dengue hemorrhagic fever with shock syndrome
Leishmania donovani causes a
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.
Dengue virus is
most common mosquito borne illness worldwide
incubation is 3-14 days and febrile illness lasts 5-7 days.
Diagnosis of dengue virus
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.
Clinical features and how leptospirosis presents
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.
leptospirosis severity
remember leptospirosis =/= leishmaniasis don’t get them confused.
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.
Treatment of leptospirosis
treat with doxycycline or penicillin
what is the clinical presentation for chikungunya fever?
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.
diagnosis of chikungunya fever?
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
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?
Chikunguyna fever
- transmitted via the aedes mosquito (also transmits ZIka and dengue)
Hantavirus is from
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
zika virus is located in
transmitted by
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.
Zika virus presnetation
conjunctivitis, mild illness but some people develop Guillian Barre Syndrome
most complications are seen with pregnant women and their babies
birth defects related to ZIKA
microcephaly
severe brain and eye defects
impared growth and fetal loss
how to prevent ZIKA virus?
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.
