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Tropical medicine - All clinical images copyright Gorgas course - : Instituto de Medicina Tropical Alexander von Humboldt > Travel medicine + Diarrhoea > Flashcards

Travel medicine + Diarrhoea Flashcards

1
Q

How many kids <5 die from diarrhoea each year

A

500,000
Most in SSA and india

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2
Q

How often do kids have diarrhoea each year

A

3 episodes per year
Peak at around 6-12 months (stop breast feeding and start crawling)

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3
Q

Name 3 risk factors for diarrhoea in children

A

Lack of breastfeeding 10x higher risk of mortality in <6m- Most important (and very cheap to fix)

Age: < 5 years, especially 6 18 months
Malnutrition
Immunosuppression
Measles
No immunizations
Lack of safe drinking water, sanitation and hygiene

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4
Q

3 categories of pathogens commonly causing diarrhoea in kids

A

Virus
rotavirus, norovirus - Top 2
[astrovirus , enteric adenovirus]

Bacteria
Shigella , Salmonella,
Campylobacter , diarrheagenic E. coli ,
Vibrio, Yersinia , Aeromonas ,
Plesiomonas

Parasites
Giardia , Crysptosporidum ,
Microsporidium , Cyclospora , Isospora ,
E. histolytica

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5
Q

What test is sensitive for bacterial diarrhoea

A

> 50 fecal leucocytes
-This indicates inflammation = likely bacterial

Key test in resource-poor places

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6
Q

Osmotic vs secretory

A

Secretory - has a toxin -> pulls water and electrolytes out

Osmostic - eg rotavirus

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7
Q

The most common cause of diarrhoea in kids <1 and globally <5 cause of death

A

rotavirus - 30% of deaths from diarrhoea

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8
Q

Types of E coli

A

ETEC - Enterotoxigenic E. coli
EPEC - Enteropathogenic E. coli
EIEC Enteroinvasive E. coli
STEC or EHEC Shigatoxin producing or EEnterohemorrhagic E. coli
EAEC - enteroaggregative E coli

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9
Q

Which e coli common to present with prolonged / chronic diarrhoea in kids

A

EPEC - Enteropatogenic E. coli

[E Paediatric/Prolonged]

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10
Q

Which e coli most common in travellers

A

ETEC - High volume watery diarrhoea
Entrotoxigenic E. coli (toxin similar to cholera toxin)

[E Traveller]

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11
Q

Which E coli is common in HIV and causes a biofilm

A

EAEC - Enteroaggregative E. coli
-As adheres can have prolonged infection
[Aggregates on itself and makes biofilm]

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12
Q

Which E coli produces shiga-like toxin -> bloody dysentery

A

EHEC (also called STEC - Shiga toxin-producing E Coli)
Especially 0157 strain

->HUS 10%
[oH HEC its the bad one]

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13
Q

Which are key pathogens for acute watery vs prolonged vs bloody vs dehydrating diarrhoea

A

Acute watery diarrhea :
rotavirus, norovirus, Cryptosporidium , ETEC, EPEC, Shigella , Campylobacter , Salmonella

Prolonged or persistent diarrhea :
EAEC, EPEC, parasites (coccidia

Bloodydiarrhea :
Shigella , Salmonella,
Campylobacter , STEC

Dehydrating diarrhea : Most important
rotavirus, ETEC, Cholera
[REC]

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14
Q

Good cheap test for shiga-like toxin

A

Latex agglutination test

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15
Q

Lots of coloisation in stool samples. How do you differentiate between colonisation and infective cause

A

PCR quantification (number of copies of DNA)

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16
Q

3 critical signs of dehydration

A

Thirst

Sensorium: irritable or comatose

Skin turgor: slow, very slow
-Best to do on abdo

[Sunken eyes, dry membranes, absent tears]

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17
Q

Mild vs mod vs severe dehydration in kids? Rx

A

A - Education and ORS
B - needs 100ml/kg in 6 hours
C - IV 20ml/kg if shocked, or 100ml/kg Oral in 6hrs

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18
Q

Key 3 measurements dehydration

A

Weight loss, blood pressure, urine output

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19
Q

Why do you not bolus Ringers lactate / polyelectrolyte solutions

A

Cant bolus stuff with K+ in

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20
Q

Key supplement for kids who have diarrhoea?

A

Zinc if >6m
- reduces symptoms and length
- prevents diarrhoea

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21
Q

What would make you want to use Abx in childhood diarrhoea

A

Fecel leucocytes > 50
Fever + bloody diarrhoea

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22
Q

Main causes of dehydrating diarrhoea

A

Rota, ETEC, Cholera

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23
Q

Explosive, watery (5-10 episodes day ), dehydrating diarrhea
Vomiting
Fever

Most likely? Key age group?

A

Rotavirus at 3-24months
[almost 100% have antibodies by 5 years]

[Norovirus second]

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24
Q

Rotavirus Dx?

A

Clinical usually

Rapid test Eg Latex agglutination / ICT
PCR
-Used if severe / outbreak / immunocompromised…
[Testing usually to prove its a viral illness -> avoid Abx]

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25
Q

Why rotavirus rare <3m

A

IgA from breast milk

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26
Q

rotavirus prevention

A

oral vaccine
Water and sanitation

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27
Q

Differentiate rota and noro in children clinically

A

Duration
Noro - <3 days
Rota - 5-8 days and slightly more severe

Both more in winter but:
-Rotavirus almost no cases in summer
-Noro all year round

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28
Q

How long excrete norovirus ? Issues with this?

A

several weeks

False positive tests down the line
Remain infectious

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29
Q

Most common cause of foodborne gastroenteritis outbreaks worldwide? - what is the classic foodstuff

A

Norovirus
Oysters

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30
Q

Why norovirus outbreaks in hospitals

A

Survive chlorhexidine / alcohol

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31
Q

Why norovirus outbreaks in hospitals

A

Survive chlorhexidine/alcohol

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32
Q

2 viruses which are similar to rotavirus but less severe? Diagnosis of these?

A

Adenovirus
astrovirus

Stool ELISA

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33
Q

What is genus shigella actually part of ?

A

E coli

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34
Q

Which shigella causes epidemics? Which common in India? Which in the industrialised world ? Which is most common? Which has most resistance? Most severe?

A
  • S dysenteriae - epidemics and severe
  • S boydii - india
  • S sonnei - industrialised and most resistance
  • S Flexneri - most common 70% of cases
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35
Q

What 2 dietary supplements are shown to reduce the incidence of dysentery

A
  • Zinc
  • Vit A
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36
Q

What produces shiga toxin? What complication may develop?

A
  • Sh dysenteriae serotype 1
    [Also produces a neuro toxin -> CNS]

HUS in around 15% of cases

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37
Q

Shigella incubation

A

1-5 days
[not less than 24hrs]

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38
Q

Shigella dx?

A
  • Stool culture - need 2
  • Fecal leukocytes helpful
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39
Q

Shigella rx? Second line?

A
  • Most ok with ORS
  • Ciprofloxacin (or another quinolone first line)
  • Azithromycin
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40
Q

Shigella prevention

A
  • Hygiene and sanitation
  • Especially hand washing when preparing food
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41
Q

Only living reservoir for shigella and cholera?

A

Humans

[cholera - also water..copepods]

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42
Q

2 parts of cholera toxin and effect

A
  • B - Binds to epithelial cells and allows entry of A
  • A - increases cAMP and causes secretion of chloride by crypt cells -> diarrhoea
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43
Q

Cholera shape and stain

A

Gram -ve comma shaped bacilli with flagella

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44
Q

Which 2 cholera sero groups cause infection? Incubation?

A
  • 01 and 0139
  • Most outbreaks are 01 form

14hrs to 5 days

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45
Q

Rx of cholera ? Which abx can be used in severe cases?? What do Abx do?

A
  • Fluid therapy
  • Azithro / doxy

Don’t improve mortality
-Reduce volume of stools and transmission
-> require less resource for management

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46
Q

Cholera control strategies

A
  • Early detection and isolation
  • Contact tracing of household
  • Longer term - improve water supply
  • Oral cholera vaccines - Variable protection (Shanchol)
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47
Q

How to make ORS if you dont have it

A

1/2 teaspoon of salt
6 tea spoons sugar
1L water

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48
Q

Which group have high rates of shigella

A

Men who have sex with men

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49
Q

When not cipro for shigella

A

Asia (commonly resistant)
-> ceftriaxone

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50
Q

Cholera key implicated foodstuff for infection

A

shellfish and crabs

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51
Q

Cholera key implicated foodstuff for infection

A

shellfish and crabs

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52
Q

Obvious risk factors for cholera such as age, malnutrition but what blood type and which infection also implicated ?

A

Blood group O
H pylori
reduced gastric acidity

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53
Q

What factors affect cholera in water ? Specifically where in water does cholera live?

A

Temp, pH, salinity, sunlight - eg el nino

Grows in alkaline conditions
Lives next to phytoplankton - uses this for nitrogen

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54
Q

Which medium required for isolation of cholera

A

TCBS
Thiosulphate-citrate bile salts-sugar agar

green coloured medium with shiny yellow cholera colonies

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55
Q

2 main serotypes of 01 cholera

A

El tor
-Survives better in environment and causes less severe disease

Classical biotypes
-Endemic in Bangladesh only
more severe

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56
Q

Most sensitive clinical finding correlating with severe dehydration eg cholera

A

Character of radial pulse

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57
Q

What extra findings in Kids with cholera

A

Fever seizures and coma more predominant
HypoK, HypoNa, HypoGly more common

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58
Q

When IV fluid choice in cholera? over how long should you initially give resus fluid

A

Severe dehydration
Not tolerating PO

Ringer’s lactate
Rehydrate over 4 hours ~100ml/kg

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59
Q

Which country has 90% of cholera at the minute

A

yemen

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60
Q

What causes typhoid? what is it called when you develop septicaemia?

A

Salmonella enterica serovar typhi (salmonella typhi)
Gram negative bacilli
Enteric fever

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61
Q

Typhoid incubation? Common sx? Complications?

A

3 days - 2 weeks depending on inoculation load

High fever, variable systemic unwell, often consitpation
Rose spots
Paradoxical normal HR / brady despite the fever

GI bleeding, perf, pneumonitis, hepatitis - usually after 3 weeks

62
Q

Typhoid dx? if poor facilities for this?

A

Blood culture

Widal agglutination test - measures antibodies to somatic (O) and flagellar (H) antigens
- not sensitive or specific

[Stool culture / bile/bone marrow aspirate]

63
Q

Who gets big bilirubin rise in typhoid?

A

G6PD

64
Q

Typhoid / paratyphoid rx? 2nd line?

A

-Cipro 1st line
[Azithro/Ceftriaxone - especially if high MDR area Eg India Pakistan]

Meropenem if really sick

65
Q

Chronic typhoid carriers tend to have salmonella living where? Important long term risk?]Rx?

A

Gall bladder -may cause chronic cholecystitis/gallstone disease
-Risk of biliary Ca

Cipro - excreted in bile [+ high concentrations in the bowel]

66
Q

Which salmonella has a vaccine? significance?

A

S typhi
Paratyphi causes 50% of infections in asia

67
Q

Typhoid from where might end up with meningoencephalitis

A

Indonesia/India

68
Q

Typhoid bloods

A

Leukopenia
Eosinopenia
Mild derranged LFTs

69
Q

Typhoid resistance to what means you cant Rx with cipro

A

Nalidixic acid

70
Q

Typhoid then 3 weeks later pain in RLQ what are you worried about

A

Ileal perf

71
Q

Most effective typhoid vaccine

A

Conjugate vaccine

72
Q

Shigella classic presentation

A

Classical presentation: watery diarrhoea for 1-2 days, then visible blood - but not massive volumes of stool

[In reality - only 40% are actually bloody]

73
Q

Shigella transmission?

A

Direct contact faecal oral
-Often from mum

Very low infectious dose - 200 bacteria only

74
Q

Key risk factors for severe shigella

A

Infants and adults > 50y
Children who are not breastfed
Children recovering from measles
Malnourished children and adults
History of seizures - 10% have seizures

75
Q

Key complication of campylobacter

A

Guillain barre

76
Q

2 main species of campylobacter

A

C Jejuni
C Coli

77
Q

Campylobacter reservoir

A

Poultry
[Pig]

78
Q

Campylobacter vs Shigella usual age in kids

A

Campy - first year of life
Shigella - Second year

79
Q

Campylobacter Rx

A

Azithromycin

80
Q

Campylobacter Dx

A

Stool cultures at 42 degrees

81
Q

Diarrhoea then 4 days later reduced urine output and pale looking what are we worried about? key features ?

A

HUS

Thrombocytopenia
Anaemia
Renal failure

82
Q

If the child presents with bloody diarrhea without fever key dx? what should you do?

A

STEC/EHEC (same thing)

NOT prescribe abx
If STEC/EHEC -> likely to augmented toxin production

83
Q

Case 1: 10 month old girl with 1 day of diarrhea with blood, 3 stools/day and fever.

Case 2: 3 year old boy with 2 days of diarrhea with mucus and blood, 7 stools/day, abdominal pain and fever.

Case 3: 6 year old boy with 4 days of diarrhea with gross blood, 6 stools/day, intense abdominal pain and no fever.

A

1 - Campylobacter as <1year
2 - Shigella
3 - STEC (bloody diarrhoea and no fever)

84
Q

Most common cause of fever in returned travller

A

Malaria - P falciparum most likely

85
Q

Fresh water exposure risk of (2)?

A

Leptospirosis, Schistosomiasis

86
Q

Exposure to rodents risk of? name 3

A

Hantavirus,
Lassa fever and other hemorrhagic fevers,
plague,
rat-bite-fever,
murine typhus

87
Q

3 risks with unpasturised dairy products

A

Brucellosis, salmonellosis, tuberculosis, Q fever, listeriosis

88
Q

Sea food and fish, raw or undercooked risk of?

A

Clonorchiasis, paragonimiasis, Vibrio, hepatitis A, gnathostomiasis, adenocephalus pacificus/dibothriocephalus latus

89
Q

Raw meat risk of?

A

Trichinellosis, salmonellosis, E.coli O157, campylobacteriosis, toxoplasmosis, gnathostomiasis

90
Q

Raw vegetables, aquatic plants (watercress), snails risk of?

A

Fasciolasis, fasciolepsiasis, angiostrongylosis

91
Q

Classic examples of a biphasic (saddleback) fever?

A

Dengue, YF, leptospirosis

92
Q

What do these signs mean? (rule in of)
Eschar:
* Chancre:
* Rose spot:
* Symmetrical arthritis of small joint:
* Conjunctival suffusion:
* Rash and conjonctivitis:
* Rash « White island on a red sea »:
* Anosmia:

A

Eschar: Rickettsiosis
* Chancre: syphilis, trypanosomiasis
* Rose spot: Enteric fever
* Symmetrical arthritis of small joint: Chikungunya
* Conjunctival suffusion: leptospirosis
* Rash and conjonctivitis: Zika
* Rash « White island on a red sea »: Dengue
* Anosmia: COVID-19

93
Q

Trip in India, Nepal, Pakistan, Bengladesh
High fever, abdominal pain, relative bradycardia = ?

A

Enteric fever

94
Q

Fresh water exposure in Malawi Lake

Fever, eosinophilia, hepatomegaly

A

Katayama fever

95
Q

Mosquito bite in urban areas in tropical country
Fever, headache, myalgia, retroorbital pain, rash, thrombocytopenia

A

Dengue

96
Q

Rafting, Thailand
Fever, myalgia, conjunctival suffusion icterus, rash

A

leptospira interrogans

97
Q

Forest in central Europe
Fever, ALC, paralysis

A

Tic bite encephalitis

98
Q

Back from a trip to subsaharian Africa Amazon, non vaccinated
Hemorragic fever, icterus, kidney failure, proteinuria

A

Yellow fever

99
Q

Trip in south Africa, safari
Fever, eschars

A

African tick-bite fever (Rickettsia africae)

100
Q

Name 3 risk factors for travellers diarrhoea

A

Daily use of a proton pump inhibitor

Low-budget or adventure travel

O blood type

Travel from an industrialized country to a developing/tropical

Age
* Being a toddler or adolescent

Lack of dietary discretion

No previous travel to a developing region

101
Q

Localised infection with fever - which organ systems are usually bacterial

A

Gastrointestinal: 80% bacterial

Genitourinary : >90% bacterial

Cutaneous : >90% bacterial

102
Q

Undifferentiated fever in Asia, Africa, and south America key causes?

A
103
Q

In rural or urban areas where do kids have more fevers? What type of pathogen?

A

Rural especially if even younger
-Usually viruses (hard to diagnose without access to serology in rural settings too)

104
Q

Key investigation in all with fever in Tropics

A

HIV test

105
Q

3 Rs of vaccines

A

Routine - ?need updated
Required - Eg yellow fever regulations
Recommended - risk is behaviour related

106
Q

Types of vaccine

A

Replicating virus vaccines
– Replicate in vaccines; longer-term immunity

Killed viruses/recombinant protein-often multi-dose
– T-cell memory; long-term immunity

Bacteria
– Always short-term protection

Polysaccharide
– Now conjugated to protein to induce T-cell
memory, booster effect, increased protection.

mRNA: naked encapsulate or viral vector

107
Q

Routine vaccines- name 5

A

Tetanus/diphtheria/pertussis
* Measles
* Polio
* Pneumococcal
* Varicella
* Influenza (separate lecture)
* HPV, Zoster

108
Q

what is the most common vaccine preventible disease in travellers

A

Influenza

109
Q

How long does flu vaccine last?

A

6 months
(decreases by about 9% per month)

110
Q

Diptheria vaccine also has? Primary series? when booster?

A

Tetanus/Diphtheria/Pertussis [Tdap vaccine]
Primary series: 0, 4 wk, 6 months
Booster after 10 years

111
Q

Measles - who is immune? Doses for protection? given with?

A

Born before 1957 = immune
2 doses - usually 12-15 months & 4-6 yr

Measles Mumps Rubella

112
Q

Varicella zoster, doses for protection? booster?

A

2 doses
No booster

113
Q

Which vaccine for shingles which is given to people > 50? What is they’ve had shingles? What if immunocompromised?

A

Shingrix
Given 2 doses usually around 2 months apart

Wait 1 year then give the vaccine series anyway

CD4 >200, otherwise decision with a consultant (usually give)

114
Q

Which polio is responsible for the ongoing infections

A

WPV1

115
Q

Which is ideal pneumococcal vaccine

A

PVC 20

116
Q

Immunocompromised how can you cover for hep A

A

Give HepA Ig - lasts 2 months

-If won’t mount response to vaccine

117
Q

How many doses for HepB

A

3 doses (0, 1, 6m unless using accelerated series)

[New expensive Heplisav-B is only 2 doses over 1 month]

118
Q

Which HepE geneotype is bad?

A

GENOTYPE 1 and 2 - 20% mortality in pregnant women

119
Q

Which vaccine still kills 1/250,000 people? Whos at risk?

A

Yellow fever

People with thymus disorders

120
Q

Who needs yellow fever booster

A

HIV, travel to west Africa

121
Q

Key meningitis geography risk ? What season?

A

Belt across Africa from Senegal/Gambia to Somalia

Dry season December-June (due to dry mucus membranes)

122
Q

Which meningitis vaccine only once licenced for kids

A

Menveo

123
Q

Important side effect of meningitis vaccine

A

Gillian barre

124
Q

Key people requiring specific MenB vaccine

A

Asplenia / complement deficiency

125
Q

Who gets cholera vaccine ?

A

Aid and refugee workers
Oral vaccine

126
Q

Which bacteria does cholera vaccine also work against

A

ETEC - has b subunit as well

127
Q

Who gets rabies PrEP ? What does it do? How many doses?

A

High-risk researchers.
long-stay travellers to high risk areas - eg rural adventure

Prevents need to get rabies Ig if exposed
2 doses day 0 and 7

They STILL NEED rabies vaccine

128
Q

Who needs rabies Ig?

A

Non-primed - eg 2 doses and >3yrs later
[If you’ve had 3 doses - you are good for life]

Also get 4 doses of the vaccine [5th dose if immunocompromised AND titres degative after 4]

129
Q

Japanese encephalitis reservoir? Breeding site? Number of vaccines?

A

Pigs
Mosquitos breed in rice paddy’s

2 vaccines 28 days apart - last 1 year
Booster after 1 year - Lasts 10 years

130
Q

Tick-borne encephalitis Vaccine number of doses

A

3 doses over 5-12 months

131
Q

Which vaccines have egg

A

yellow fever, measles, mumps, flu

132
Q

Which vaccines contain neomycin

A

measles, mumps, rubella,
varicella

133
Q

Which vaccine contains streptomycin

A

Oral polio vaccine

134
Q

which vaccines do you not give in pregnancy

A

Generally just the ones you don’t give to immunocompromised

You Musn’t Prescribe BCG Incase They RIP Stat

MMR, varicella, Ty21a, live influenza, HPV
 Killed influenza wait till 2nd trimester in
many countries

135
Q

Antimalarials contraindicated in pregnancy

A

Doxycycline, Malarone, Tafenoquine Primaquine

DMTPeople
[Artemisinins actually fine]

136
Q

Acetazolamide in pregnancy

A

NOT Safe

137
Q

Breast feeding which vaccine big big contraindicated

A

Yellow fever

138
Q

Which ART class most interactive with antimalarials? Which antimalarial worst

A

protease inhibitors most problematic ART drug.

mefloquine is the most problematic;

139
Q

3 vaccines recommended for all travellers

A

Typhoid
HepA
HepB

140
Q

which meningococcal strain is not in the primary series vaccine

A

B
[Men ACYW]

141
Q

2 complications of flu vaccine

A

Egg allergy
Gillian-barre

142
Q

Name 3 complications of PID

A

Infertility
Chronic pelvic pain
Ectopic pregnancy

143
Q

PID rx

A

Cef + doxy + metronidazole

144
Q

Gonrrhorea / chlamydia rx

A

Gon - Ceftriaxone
Chlamid - Doxy

145
Q

Mycoplasma genitalium rx

A

Doxy + azithro/moxifloxacin

146
Q

Gonococcal vs reactive arthritis

A

Gonococcal
-Tendosynovitis
-Migratory polyarthritis
- Rash which may pustulate

Reactive
-Tendosynovitis rare
- Rash affects palms / soles

147
Q

Difference between immigrant and refugee

A

Immigrants choose to move,
whereas refugees are forced to flee

148
Q

Name 5 things you could screen for in a refugee

A
149
Q

Which migrants should get varicella vaccine?

A

All kids <13
Screen if >13 and vaccinate if no antibodies

150
Q

name 2 conditions VFRs have in particularly high rates when compared with other travellers

A

malaria, hepatitis A and typhoid

151
Q

Most common deficiency worldwide

A

Iron

Tropical medicine - All clinical images copyright Gorgas course - : Instituto de Medicina Tropical Alexander von Humboldt (26 decks)

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