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Year 3 - Infection > Travel related infection > Flashcards

Travel related infection Flashcards

1
Q

Who is the “father of Tropical Medicine” ?

A

Sir Patrick Manson MBChB, Aberdeen 1865:
> Discovered cause of Filariasis (Elephantiasis)
> Founded London School of Tropical Medicine

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2
Q

Unfamiliar features of imported diseases?

A 
> Presenting features
> Isolation requirements 
> Diagnostic methods
> Treatment/Management
> Unexpected complications
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3
Q

Vulnerability of travelers to infection?

A

> Temptation to take risks away from home:

  • food, water
  • animals
  • sex

> Different epidemiology of some diseases:

  • HIV
  • TB
  • polio
  • diphtheria

> Incomplete understanding of health hazards

> Stress of travel

> Refugees: deprivation, malnutrition, disease, injury

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4
Q

Infections which are common worldwide?

A

> Influenza
Community-acquired pneumonia
Meningococcal disease
Sexually transmitted diseases

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5
Q

Climate or environment related health problems when travelling??

A 
> Sunburn
> Heat exhaustion and heatstroke
> Fungal infections
> Bacterial skin infections 
> Cold injury
> Altitude sickness
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6
Q

Water-related infections when travelling?

A 
> Schistosomiasis
> Leptospirosis
> Liver flukes
> Strongyloidiasis
> Hookworms
> Guinea worms
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7
Q

Arthropod-borne infections when travelling?

A

> Malaria (mosquitos)
Dengue fever (mosquitos)
Rickettsial infections (ticks: typhus)
Leishmaniasis (sand flies: Kala-azar)
Trypanosomiasis (tsetse fly: sleeping sickness)
Filariasis (mosquitoes: elephantiasis)
Onchocerciasis (black flies: River Blindness)

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8
Q

Which arthropod causes malaria?

A

Mosquitos

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9
Q

Which arthropod causes dengue fever?

A

Mosquitos

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10
Q

Which arthropod causes typhus (rickettsial infection)?

A

Ticks

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11
Q

Which arthropod causes kala-azar (Leishmaniasis)?

A

Sand flies

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12
Q

Which arthropod causes sleeping sickness (trpanosomiasis)?

A

Tsetse fly

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13
Q

Which arthropod causes elephantiasis (filariasis)?

A

Mosquitos

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14
Q

Which arthropod causes river blindness (onchocerciasis)?

A

Black flies

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15
Q

Emerging Infectious Diseases worldwide?

A 
> Zika: Latin America, Caribbean
> Ebola virus disease: West Africa
> MERS-CoV: Middle East 
> Swine ‘flu (H1N1): worldwide
> Avian ‘flu (H5N1 and H7N9): China
> SARS: Far East, worldwide
West Nile Virus: USA
…etc.
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16
Q

Important Tropical Diseases?

A 
> Malaria
> Typhoid
> Dengue Fever
> Schistosomiasis
> Rickettsiosis
> Viral haemorrhagic fevers
> Zika fever
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17
Q

Malaria epidemiology?

A

> United Kingdom (HPA, 2015)

  • 1400 cases/year
  • 6 deaths/year

> Worldwide (WHO, 2012)

  • 207 million cases/year
  • 627,000 deaths/year
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18
Q

The Malaria vector?

A

female Anopheles mosquito

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19
Q

What is the malaria life cycle?

A

1) Mosquito bites human
2) Delivers sporozoite
3) Taken up by liver cells
4) Merozoites produced
5) Taken up into RBC
6) Destroys RBCs
7) Bite by mosquito
8) Female gametocyte taken up by mosquito
9) Gametocyte –> Zygote –> Sporozoite
10) Next human bitten
11) Sporozoite delivered

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20
Q

What are the 5 malaria species?

A

Potentially severe:
- Plasmodium falciparum

Benign:

  • Plasmodium vivax
  • Plasmodium ovale
  • Plasmodium malariae
  • Plasmodium knowlesi
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21
Q

Which malarial species in potentially severe?

A

Plasmodium falciparum

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22
Q

What are the symptoms of malaria?

A

SYMPTOMS:

  • fever
  • rigors
  • aching bones
  • abdo pain
  • headache
  • dysuria
  • frequency
  • sore throat
  • cough
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23
Q

What are the signs of malaria?

A

SIGNS:

  • none
  • splenomegaly
  • hepatomegaly
  • mild jaundice
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24
Q

What are the complications of malaria?

A

1) Cerebral malaria (encephalopathy):
- non- immune visitors
- children in endemic areas hypoglycaemia, convulsions, hypoxia

2) Blackwater fever:
- severe intravascular haemolysis
- high parasitaemia
- profound anaemia
- haemoglobinuria
- acute renal failure

3) Pulmonary oedema
4) Jaundice
5) Severe anaemia

6) Algid malaria:
- Gram-negative septicaemia

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25
Q

What are the complications of malaria - Cerebral malaria (encephalopathy)?

A

Cerebral malaria (encephalopathy):

  • non- immune visitors
  • children in endemic areas hypoglycaemia, convulsions, hypoxia
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26
Q

What are the complications of malaria - Blackwater fever?

A

Blackwater fever:

  • severe intravascular haemolysis
  • high parasitaemia
  • profound anaemia
  • haemoglobinuria
  • acute renal failure
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27
Q

Management of malaria in adults, guidelines

A

> UK malaria treatment guidelines 2016
Lalloo DG et al. J Infect 2016; 72: 635-649
http://dx.doi.org/10.1016/j.jinf.2016.02.001

> BNF

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28
Q

How is malaria diagnosed?

A

> Thick & thin blood films:

  • Giemsa
  • Field’s stain

> Quantitative buffy coat (QBC)

  • centrifugation
  • UV microscopy

> Rapid antigen tests:

  • OptiMal
  • ParaSight-F
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29
Q

How is severity is malaria assessed?

A

Complicated malaria in one or more of:
> Impaired consciousness or seizures

> Hypoglycaemia

> Parasite count 2%

> Haemoglobin  8mg/dL

> Spontaneous bleeding / DIC

> Haemoglobinuria

> Renal impairment or pH <7.3

> Pulmonary oedema or ARDS

> Shock (algid malaria)
?Gram negative bacteraemia

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30
Q

Natural drugs used in malaria treatment?

A

> Quinine from Chinchona

> Artemisinins from Quinghaosu

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31
Q

Treatment options for uncomplicated P. falciparum malaria?

A

Riamet ® (artemether-lumefantrine) 3 days

Eurartesim ® (dihydroartemisinin-piperaquine) 3 days

Malarone ® (atovaquone-proguanil) 3 days

Quinine 7 days
S/E nausea, tinnitus, deafness (cinchonism), rash, hypoglycaemia
plus oral doxycycline (or clindamycin)

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32
Q

Treatment options for complicated P. falciparum malaria?

A

1) IV artesunate (unlicensed in UK)

2) IV quinine
(S/E cardiac depression, cerebral irritation, N&V)
plus oral doxycycline (or clindamycin)

When patient is stable & able to swallow, switch to oral treatments

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33
Q

Treatment of

P. vivax, P. ovale, P. malariae, P. knowles?

A

chloroquine 3 days

Riamet ® (artemether-lumefantrine) 3 days

add primaquine* (14 days) in vivax and ovale, to eradicate liver hypnozoites

*check for G6PD deficiency

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34
Q

Malaria Control Programmes?

A

Mosquito breeding sites:
- Drainage of standing water

Larvacides:

  • (Paris green)
  • temphos
  • biological

Mosquito killing sprays:

  • DDT
  • malathion, (dieldrin)

Human behaviour:

  • Bed nets
  • Mesh windows
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35
Q

Pathogen that causes typhoid (enteric) fever?

A

Salmonella typhi

Salmonella paratyphi

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36
Q

Typhoid (Enteric) fever epidemiology?

A

Global cases: 27 million infections/yr

Global deaths: over 200,000/yr

UK cases: 500/yr

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37
Q

What is the main cause of widespread Typhoid (Enteric) fever?

A
  • Poor sanitation

- Unclean drinking water

38
Q

Typhoid Fever: Clinical features?

A

> Incubation period: 7 days - 4 week

> 1st week:
fever, headache, abdo. discomfort, constipation, dry cough, relative bradycardia, neutrophilia, confusion

> 2nd week:
fever peaks at 7-10 days, Rose spots, diarrhoea begins, tachycardia, neutropenia

> 3rd week (Complications):
intestinal bleeding, perforation, peritonism, metastatic infections

> week 4 (Recovery):
10 - 15% relapse

39
Q

What is the incubation period of typhoid fever?

A

7 days - 4 week

40
Q

What occurs within the 1st week of typhoid fever?

A 
> fever
> headache
> abdomen discomfort
> constipation
> dry cough
> relative bradycardia
> neutrophilia
> confusion
41
Q

What occurs within the 2nd week of typhoid fever?

A 
> fever peaks at 7-10 days
> Rose spots
> diarrhoea begins
> tachycardia
> neutropenia
42
Q

What occurs within the 3rd week of typhoid fever?

A 
3rd week (Complications): 
> intestinal bleeding
> perforation
> peritonism
> metastatic infections
43
Q

What occurs within the 4th week of typhoid fever?

A 
week 4 (Recovery): 
10 - 15% relapse
44
Q

How is typhoid fever diagnosed?

A

Clinical

  • not easy
  • evolution of features

Laboratory (Salmonella typhi, S. paratyphi)

  • Culture blood, urine & stool
  • Culture bone marrow
45
Q

Typhoid Fever: Treatment?

A

Oral Azithromycin
- now drug of choice for Asian-acquired, uncomplicated enteric fever

IV Ceftriaxone
- if complicated, or concerned regarding absorption

Increasing ciprofloxacin resistance

46
Q

What is the most common human arbovirus infection?

A

Dengue - Swahili “Ki-Dinga pepo”

47
Q

How many cases of dengue infection?

A

100 million cases/year

48
Q

How many deaths caused by dengue each year?

A

25,000/year

49
Q

How is dengue fever transmitted?

A

Aedes aegypti - Mosquito

50
Q

Classical presentation of dengue fever?

A

> Sudden fever

> Severe headache, retro-orbital pain

> Severe myalgia and arthralgia

> Macular/ maculopapular rash / petichial rash

> Haemorrhagic signs: petechiae, purpura, positive tourniquet test

51
Q

Dengue Diagnosis?

A

Clinical

  • Thrombocytopenia
  • Leucopenia
  • Elevated transaminases
  • Positive tourniquet test

Laboratory: PCR, serology

52
Q

Dengue Management?

A

No specific therapeutic agents

Complications

  • Dengue haemorrhagic fever (DHF)
  • Dengue shock syndrome (DSS)
  • Rx: IV fluids, fresh frozen plasma, platelets

Prevention

  • avoid bites
  • new vaccine (Dengvaxia), 2016; limited use
53
Q

Complications of Dengue fever and how to manage?

A

Complications

  • Dengue haemorrhagic fever (DHF)
  • Dengue shock syndrome (DSS)
  • Rx: IV fluids, fresh frozen plasma, platelets
54
Q

Sources of Schistosomiasis?

A
  • Fresh water

- Freshwater snails

55
Q

Species of Schistosomiasis?

A

S. haematobium
S. mansoni
S. japonicum

56
Q

Lifecycle of Schistosomiasis?

A

1) Schistosomiasis from Faeces or urine
2) Eggs hatch releasing miracidia
3) Miracidia penetrate snails tissue
4) Sporocysts in snail (successive generations)
5) Cercariae released by snails into water and free-swimming (Infective stage)
6) Penetrate skin
7) Cercariae lose tails during penetrating and becoming schistosomulae
8) Circulation
9) Migrate to portal blood in liver and mature into adults
10) Paired adult worms migrate to mesenteric venules of bowel/rectum (Eggs released in stools)

57
Q

Schistosomiasis - Clinical features?

A 
Swimmers Itch (1st few hrs)
- clears 24-48hrs 
Invasive stage (after 24hrs)
- cough, abdo discomfort, splenomegaly, eosinophilia
Katayama Fever (after 15-20 days):
- prostrate, fever, urticaria, lymphadenopathy, splenomegaly, diarrhoea, eosinophilia
Acute disease (6-8 weeks)
eggs deposited in bowel (dysentery) or bladder (haematuria)

Chronic disease

58
Q

Schistosomiasis - Clinical features, first few hours?

A

Swimmers itch, clears for 24-48 hours

59
Q

Schistosomiasis - Clinical features, after 24 hours?

A

Invasive stage:

  • Cough
  • Abdomen discomfort
  • Splenomegaly
  • Eosinophilia
60
Q

Schistosomiasis - Clinical features, after 15-20 days?

A

Katayama Fever (after 15-20 days):

  • prostrate
  • fever
  • urticaria
  • lymphadenopathy
  • splenomegaly
  • diarrhoea
  • eosinophilia
61
Q

Schistosomiasis - Clinical features, 6-8 weeks?

A

Acute disease (6-8 weeks) = eggs deposited in bowel (dysentery) or bladder (haematuria)

62
Q

Schistosomiasis - Clinical features, after 8 weeks?

A

Chronic disease

63
Q

Diagnosis of schistosomiasis?

A

Diagnosis

  • Clinical diagnosis
  • Antibody tests
  • Ova in stools and urine
  • Rectal snip
64
Q

Treatment of schistosomiasis?

A

Treatment

  • PRAZIQUANTEL 20mg/kg, two doses 6hrs apart
  • Prednisolone if severe
65
Q

What does Rickettsiosis cause?

A 
> Tick typhus (R. conorii, R africae)
> Rocky Mountain Spotted Fever (R. rickettsii)
> Epidemic typhus (R. prowazekii)
> Murine or endemic typhus (R. mooseri)
> Scrub typhus (R. tsutsugamushi)
> others
66
Q

Which species of Rickettsiosis cause Tick typhus?

A

R. conorii, R africae

67
Q

Which species of Rickettsiosis cause Rocky Mountain Spotted Fever?

A

R. rickettsii

68
Q

Which species of Rickettsiosis cause Epidemic typhus?

A

R. prowazekii

69
Q

Which species of Rickettsiosis cause Murine or endemic typhus?

A

R. mooseri

70
Q

Which species of Rickettsiosis cause Scrub typhus?

A

R. tsutsugamushi

71
Q

With cases of tick typhus in the UK which countries is the source usually?

A
  • Southern Africa
  • Mediterranean
  • Arabian Gulf
72
Q

What are the clinical features of Rickettsiosis?

A

Clinical features:

  • Abrupt onset swinging fever
  • headache
  • confusion
  • endovasculitis
  • rash (macular, petechial)
  • bleeding
73
Q

How is Rickettsiosis diagnosed?

A

Diagnosis: clinical features, serology

74
Q

How is Rickettsiosis managed?

A

Tetracycline

75
Q

Viral haemorrhagic fever outbreaks in Congo?

A

Ebola, 2007

76
Q

Viral haemorrhagic fever outbreaks in Sierra Leone?

A

Ebola, 2013-2016

77
Q

Viral haemorrhagic fever outbreaks in Guinea and Liberia?

A

Ebola, 2013-2016

78
Q

Viral haemorrhagic fever outbreaks in Glasgow?

A

CCHV, 2012

Ebola, 2014, 2015

79
Q

Viral haemorrhagic fever in the UK?

A

Serious infections but rare in UK:

  • Ebola
  • Congo-Crimea haemorrhagic fever
  • Lassa fever
  • Marburg disease
80
Q

What must occur if a haemorrhagic fever is diagnosed?

A

High security infection unit and supportive therapy

81
Q

What is the cause of zika?

A

Flavivirus

82
Q

How is Zika (flavivirus) transmitted?

A

Daytime-biting Aedes Mosquitos

Also sexual contact and blood transmission

83
Q

What is Zika (flavivirus) related to?

A
  • dengue,
  • yellow fever
  • Jap B encephalitis
  • West Nile viruses
84
Q

Outbreaks of Zika (flavivirus)?

A

> Pacific outbreak, 2013-2014

> Latin America pandemic 2015-2016

85
Q

Clinical features of Zika?

A

Clinical, no or mild symptoms:

  • headache
  • rash
  • fever
  • malaise
  • conjunctivitis
  • joint pains (like dengue)

In pregnancy, can cause microcephaly and other neurological problems

Can cause Guillain-Barre syndrome

86
Q

How is Zika treated?

A

There is no antiviral therapy

Mosquito control measures

Vaccines development

87
Q

Which questions should be asked in travellers disease?

A 
History:
> Is it tropical?
> Travel history
> Precautions taken
> Risks
> Symptoms
> Incubation periods
88
Q

In travellers disease if there is a rash what should you consider?

A
  • Typhoid
  • Typhus
  • Dengue
89
Q

In travellers disease if there is a jaundice what should you consider?

A
  • Hepatitis
  • Malaria
  • Yellow fever
90
Q

In travellers disease if there is a lymph nodes what should you consider?

A
  • Leishmania

- Trypanosomiasis

Year 3 - Infection (16 decks)

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