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Infection > Y4 - Infection in the Returning Traveller > Flashcards

Y4 - Infection in the Returning Traveller Flashcards

1
Q

If a patient turns up to their GP with a fever after being abroad what MUST you do before referring them to hospital?

A

Do a risk assessment for viral haemorrhagic fevers

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2
Q

Why is it important to know the dates of travel?

A

As they link to the incubation periods of the pathogens

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3
Q

Give examples of viral haemorrhagic fevers

A 
Ebola
Lassa fever
Crimean-Congo HF
Dengue 
Yellow fever
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4
Q

What are haemorrhagic fevers?

A

Severe, multi-organ disease in which the endothelium is damaged and homeostasis is impaired

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5
Q

What kind of virus is dengue?

A

Flavivirus

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6
Q

How is dengue transmitted?

A

Aedes mosquito bite

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7
Q

When do the Aedes mosquitoes bite?

A

Day time

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8
Q

What is the incubation period of dengue?

A

3-14d

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9
Q

What is the presentation of dengue?

A

Fever, NV, headache, retroorbital pain, arthralgia

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10
Q

How do you investigate dengue?

A

PCR for virus or serology after 5d

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11
Q

What drug should you avoid using in someone with dengue?

A

NSAIDs

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12
Q

What is the treatment of dengue?

A

Supportive (fluids, analgesia etc.)

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13
Q

Name 4 diseases spread by mosquitos

A

Dengue
Malaria
Elephantiasis
Yellow fever

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14
Q

True or false: malaria treatment should be started empirically

A

FALSE

Only on diagnosis, hence why if malaria is suspected then malarial blood film must be done on call

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15
Q

In who should you always think about a diagnosis of viral haemorrhagic fever?

A

Any traveller with fever presenting within 21d of return to the UK

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16
Q

What sort of things would indicate a high risk of a VHF?

A

Fever/hx of fever in past 24h
Developed symptoms w/I 21d of leaving VHF endemic country
Come into contact with body fluids/clinical specimens from individual strongly suspected to have VHF w/I last 21 days

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17
Q

If you really suspect VHF what should you do?

A

ISOLATE patient
Urgent malaria investigation
FBC, U&Es, LFTs, clotting screen, CRP, glucose, blood cultures
Inform lab of possible VHF case
Hand hygiene, double glove, full length apron etc.

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18
Q

If there is a low risk of VHF in patient returning with fever after travel what should you do?

A

Urgent malaria investigation
Local investigations, e.g. blood cultures
Standard IPC (hand hygiene, apron, gloves)

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19
Q

If a patient returns from travel, presenting with a fever within 21d and malaria test is negative, what is the treatment protocol?

A

If patient has extensive bruising, active bleeding, uncontrolled diarrhoea/vomiting or is unfit for outpatient management –> ADMIT
VHF test positive –> launch public health actions, need high level isolation unit

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20
Q

What are the reservoirs for Ebola?

A

Fruit bats

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21
Q

What is the pathogenesis of Ebola?

A

Cytokine activation leads to endothelial damage, oedema, coagulopathy and tissue necrosis leading to multi-organ failure

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22
Q

How is Ebola spread?

A

Direct contact with mucous membranes/bodily fluids, burial contact

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23
Q

What is the presentation of Ebola?

A

0-3d: fever, myalgia, weakness, anorexia, headache, sore throat
4-10d: ab pain, liver tenderness, NV, hiccups, diarrhoea, hypovolaemia
>10d: haemorrhagic: petechiae, ecchymosis, mucosal haemorrhage, GI bleeding, haemoptysis; neurological: weakness, confusion, agitation, coma and others

May get post infection conditions, e.g. arthralgia, hepatitis, orchitis, transverse myelitis etc.

24
Q

How do you diagnose Ebola?

A

Serology

Reverse transcriptase PCR on blood/urine/saliva/throat swab

25
Q

How do you treat Ebola?

A

Supportive (fluid resus, correct electrolytes/coagulation etc.)
Trace contacts

26
Q

What is the risk assessment for VHF in the UK?

A

Transmission: 1. travel to endemic area or lived/worked in rural conditions (Lassa fever) or visited caves/mines or been in contact with/eaten primates/antelopes or bats in Marburg/Ebola endemic areas or been involved with animal slaughter (CCHF) 2. travel to known outbreak 3. contact with infected specimen

Fever >37.5C in last 24h

27
Q

What are the species that cause malaria?

A 
Plasmodium species
P. falciparum
P. knowlesi 
P. malariae
P. ovale 
P. vivax
28
Q

What type of mosquitos carry malaria?

A

Females anopheles
Only females require a bloodmeal for egg development

Transmission in absence of a mosquito is rare (e.g. vertical, transfusion etc.)

29
Q

Fill in the blanks:

_________ are transferred to a human host when an infected mosquito bites. These travel via the blood to the _______ where maturation occurs to form _______ which contain around 30, 000 __________ offspring. If a dormant stage exists (vivax, ovale) ______ can be released from the ______ years later. ________ enter RBCs, there they form ________ and erythrocytic ______. Rupture of these leads to the clinical manifestations of malaria.

A 
Sporozytes
Liver
schizonts
Merozoites
Merozoites 
Liver
Merozoites
Larger trophozoites 
Schizonts
30
Q

How long does it take most people infected with P. falciparum to have symptoms?

A

Less than 3 months

31
Q

What are the symptoms of malaria?

A

Fever, headache, malaise, myalgia, diarrhoea, cough

May have fever patterns

32
Q

What are the signs of malaria?

A

May be none

If diagnosis delayed/severe disease may present with jaundice, confusion, seizures

33
Q

How do you diagnose malaria?

A

Thick and thin blood smear
Rapid diagnostic test detection of parasite antigen may be used in addition but not instead of blood smear
Results must be available within 4 hours
Parasite count must be given for P. falciparum

34
Q

What are differentials for malaria?

A 
Dengue
Typhoid
Hepatitis
Meningitis/encephalitis
HIV
VHF
35
Q

What other investigations should you do for malaria?

A

FBC (anaemia, thrombocytopenia), creatinine, urine output, clotting (DIC), glucose (hypoglycaemia), ABG/lactate (acidosis), urinalysis (haemogobulinuria)
Blood culture for typhoid
CXR to exclude community acquired pneumonia

36
Q

How do you manage complicated falciparum malaria?

A

Admit to hospital (may need ITU/HDI)
Supportive care: oxygen, fluids, ECG monitoring and blood glucose monitoring (esp during IV quinine)
4hrly obs
Repeat FBC, clotting, U&Es, LFTs and parasite count daily
Antimalarials:
- Artesunate IV 2.4mg/kg at 0, 12, 24hrs for 7 days + doxycycline or clindamycin

37
Q

How long is the incubation period of malaria?

A

At least 6 days

38
Q

What is complicated malaria?

A

1 or more of:

  • impaired consciousness/seizures (CHECK blood glucose straight away)
  • Hypoglycaemia
  • Parasite count 2% or more
  • Hb 8d/dL or less
  • Spontaneous bleeding/DIC
  • Haemoglobulinuria without G6PD deficiency
  • Renal impairment/electrolyte/acid base disturbance (pH <7.3)
  • Pulmonary oedema/ARDS
  • Shock (algrid malaria) may be due to gram negative bacteraemia
39
Q

How do you treat uncomplicated falciparum malaria?

A

a) oral quinine 600mg/8h plus doxycycline 200mg daily (or clindamycin 450mg/8h) for 7 days
b) malarone - 4 tablets daily for 3 days
c) Riamet - wt >35kg, 4 tablets and then 4 tablets at 8, 24, 36, 48 and 60h

40
Q

How do you treat non-falciparum disease?

A

If severe Rx as falciparum

If not severe - chloroquine

41
Q

How do you prevent malaria?

A

Vector control (e.g. insecticidal nets, sterile male mosquito release, destruction of breeding sites etc.)
Chemoprophylaxis
- no drug resistance: chloroquine/proguanil
- little chloroquine resistance: chloroquine and proguanil
- chloroquine resistant P. falciparum: mefloquine, doxycycline

Bite prevention - DEET

42
Q

Where does typhoid tend to affect travels?

A

India, Pakistan etc.

43
Q

What causes typhoid?

A

Salmonella typhi

44
Q

Where do salmonella typhi invade?

A

Intestinal mucosa

But dissemination occurs without a primary diarrhoea

45
Q

What is the transmission of typhoid?

A

Faecal-oral from contaminated food/water

46
Q

How do you diagnose typhoid?

A

Culture from blood sample

47
Q

What are the clinical features of typhoid?

A

Fatigue, headache, anorexia, fever

May also get diarrhoea, ab pain, hepatosplenomegaly, rose spots, cough, constipation

48
Q

How do you treat typhoid?

A

Azithromycin & IV ceftriaxone

49
Q

What causes typhus?

A

Infection with rickettsial bacteria

Flea born typhus in tropical areas or louse-borne typhus in homeless populations

50
Q

How do you diagnose typhus?

A

Clinical: fever, rash, travel to endemic area
PCR/culture of blood/skin biopsy
Serology

51
Q

How do you Rx typhus?

A

Antibiotics in severe cases (e.g. azithromycin, doxycycline)

52
Q

What is schistosomiasis?

A

Liver fluke

53
Q

What can schistosomiasis cause if left untreated?

A

Chronic scarring causing uropathy or portal hypertension

54
Q

How do you Rx schistosomiasis?

A

Praziquantel

55
Q

What is strongyloides?

A

A helminth that can cause a hyperinfection syndrome if someone becomes immunosuppressed
(Marked eosinophilia)

Infection (22 decks)

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