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Differentiation of Post-Travel Fever in a 25 Year-Old Medical StudentAuthor(s): Brent Mittelstaedt, Brigitte Flanagan, John Burdick, and William Perry BakerSource: Journal of the Arizona-Nevada Academy of Science, 40(2):163-164. 2008.Published By: The Arizona-Nevada Academy of ScienceDOI: http://dx.doi.org/10.2181/1533-6085-40.2.163URL: http://www.bioone.org/doi/full/10.2181/1533-6085-40.2.163

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DIFFERENTIATION OF POST-TRAVEL FEVER IN A 25 YEAR-OLD MEDICAL STUDENT

BRENT MITTELSTAEDT, BRIGITTE FLANAGAN, JOHN BURDICK, Arizona College of Osteopathic Medicine,Midwestern University, Glendale, AZ 85308; and WILLIAM PERRY BAKER, Southwestern College, 2625 E Cactus Rd, Phoenix, AZ 85032

ABSTRACTWe report an unusual case of post-travel fever, extreme headache, chills, nausea, vomiting, profuse diarrhea and clinical

sepsis. The patient had been in excellent health prior to a month-long rotation in Samoa and American Samoa where he had directpatient contact. He also traveled to remote villages, frequently ate local food and swam in both fresh and saltwater. Symptomsdeveloped 5 days post return and on day eight the patient was hospitalized and resuscitated with intravenous fluids. Antibioticsadministered empirically included IV levofloxacin, IV metronidazole and IV vancomycin. His condition gradually improved withnormalization of lab values. However AST and ALT levels remained elevated. Despite advances in diagnosis, post-travel feversremain a challenging clinical problem. Lessons learned from this patient's care will inform readers of current methods of diagnosisand treatment. Implications for travel to remote locales are discussed.

HISTORY AND PHYSICALA 25-year-old male medical student presented at a

community emergency room with fevers, malaise, chills,headache, nausea, vomiting and profuse diarrhea. Thepatient had been in excellent health prior to amonth-long rotation in Samoa and American Samoa.Vital signs demonstrated a temperature of 103.9EF,blood pressure of 90/48, pulse of 140, and respirationsof 70. Physical exam showed a weak-appearing patientwith normal mental status, no lymphadenopathy, no orallesions, no neck stiffness, clear chest and normal heartsounds. There was no hepatosplenomegaly, abdominaltenderness, guarding or rebound. Joint tenderness wasabsent. There were no skin rashes. Initial lab valueswere significant for thrombocytopenia (78K) andanemia (Hgb 10). Coagulation study abnormalitiesincluded a d-dimer of 9.24 and a fibrinogen of 460.Chest x-ray was negative for abnormalities as was hisabdominal x-ray. Abdominal ultrasound and computedtomography showed an edematous gallbladder, rightpleural effusion, trace ascites, fatty infiltration of theliver with mild hepatosplenomegaly, and nohydronephrosis. Computerized tomography of theabdomen without contrast confirmed the ultrasoundfindings, showing gall bladder thickening (withsuggestion of pericholecystic fluid), fatty infiltration ofthe liver, bilateral pleural effusions and subjacentinfiltrate or atelectas. No ova, parasites, few yeast andfew WBCs were seen on wet mount of stool. Blood,stool and urine cultures were negative. Serology for C.difficile toxins, platelet antibody IgG, ANA, ANCA(Proteinase-3 Ab and Myeloperoxidase Ab), LymeDisease, GBM Ab, HIV, West Nile Ab IgG/IgM, Hep Bcore antigen, R. typhus IgG and IgM (typhi IgG/IgM),Hep C IgM/IgG and Rocky Mountain Spotted FeverIgG/IgM were negative. Hep A was reactive from priorvaccination (2003).

HOSPITAL COURSEThe patient was resuscitated with intravenous fluids

and hospitalized for six days. Six consultations wereobtained (Renal, Medicine, Surgery, Infectious Disease,GI and Hematology). Antibiotics administered empiri-cally included IV levofloxacin, IV metronidazole and IVvancomycin. Diarrhea ceased on hospital day four.Creatinine elevated to a level of 2.0, but lowered to 1.2by discharge. Acetominophen with oxycodone was pre-scribed for headache. During his hospital stay the patientgradually improved except for AST and ALT whichremained elevated (171 and 160, respectively). Liverenzymes returned to normal three weeks post discharge.Oral antibiotics in the outpatient setting included tendays of clarithromycin and seven days of metronidazole.

DIFFERENTIALEndemic diseases recognized in Samoa and

American Samoa include leptospirosis, typhoid andparatyphoid (enteric fever), dengue fever, and hepatitisA. The areas are both free from malaria. Urinalysis withthe presence of WBC's and blood, septic shock(including renal insufficiency, thrombocytopenia andsigns of hemolysis/DIC) are common in severe cases oftyphoid fever, leptospirosis and dengue fever. Profusediarrhea is a non-specific finding and the differential caninclude any number of enteric pathogens.

DISCUSSIONDespite advances in diagnosis, post-travel fevers

remain a challenging clinical problem. We attempt todiscuss several learning points which may be of interestto clinicians presented with this dilemma.

1. Know the tropical differential. The importance ofconsidering illnesses endemic to the area of travel is avery important factor in determining a differential for a

MITTLEDSTAEDT, B., B. FLANAGAN, J. BURDICK, AND W. P. BAKER. 2008. DIFFERENTIATION OF POST-TRAVEL FEVER IN A 25-YEAR-OLD MEDICAL STUDENT. JOURNAL OF THE ARIZONA-NEVADA ACADEMY OF SCIENCE 40(2):163-164.

164 DIFFERENTIATION OF POST-TRAVEL FEVER g MITTLESTAEDT ET AL.

traveler. Dengue fever, leptospirosis, and enteric feverare very much a possibility given their prevalence inSamoa and American Samoa. Testing could have beendone for these diseases in addition to following a path ofcommon gastroenteritis differentials. Choosing the testsappropriate to those differentials in addition to thediseases encountered in suburban practice is imperative.

2. Know the tests and lab work available at yourinstitution. Consultation with the state health departmentfor the possibility of advanced testing by them or theCDC is warranted in cases of tropical diseases. As forin-house laboratory analysis, our patient had blood, stooland urine cultures performed and a Widal's test.

3. Obtain blood cultures as soon as possible. Ourpatient was admitted for 12 hours before blood cultureswere taken. IV antibiotics were administered in theemergency room before admission. Chances of isolatinga culture of a bacteria from blood after IV antibiotics areinitiated are reduced dramatically and this could haveplayed a role in the non-diagnosis of our patient.

4. Narrow down treatment as soon as possible. Ourpatient was placed on levofloxacin, vancomycin andmetronidazole presumably because of the acuity of hisillness and large differential. Metronidazole is com-monly used for amoebas and anaerobes, but the lab workfor these were negative. The fluoroquinolones are theantibiotics of choice to treat increasingly widespreadmultidrug-resistant typhoid fever. Doxycycline, ampicil-lin or amoxicillin are drugs of choice for leptospirosisand should lead to resolution in 7-10 days. It is usuallyself-limiting and children under 8 should not be treatedwith doxycycline. Severe cases should be treated withIV penicillin G. (Bradley and Swartz. 2005). There is nospecific management of dengue infections, no vaccine iscommercially available, and vector control is the onlyalternative for controlling the spread of the disease(Basnyat et al. 2005). Attenuated dengue vaccines are inthe last stages of development and have producedpromising results in early tests (Basnyat et al. 2005)Knowledge of several aspects of dengue infections,especially of diagnosis and vaccine development, iscontinuously evolving, but several issues are stillunresolved (Bradley and Swartz 2005).

5. Importance of the pre-travel consultation. Whilecertain clinical features may suggest specific etiologicalagents, empirical treatment is often required when noidentifiable pathogen is found. Prevention is thereforerecommended. Pre-travel consultation is recommendedto reduce food, water and environmental exposures andshould be part of every traveler's preparation.Discussion of prophylactic measure may have kept thispatient out of the hospital. Vaccine prophylaxis is animportant part of traveling to areas endemic with entericfevers (Blair 2004).

LITERATURE CITEDBLAIR, J. E. 2004. Evaluation of fever in an interna-

tional traveler. Postgraduate Medicine 2004:116.BRADLEY, C., and E. SWARTZ. 2005. Typhoid &

paratyphoid fever in travelers. The Lancet 5:623-628.

BASNYAT, B., A. MASKEY, M. ZIMMERMAN, and D.MURDOCH. 2005. Enteric typhoid fever in travelers. Travel Medicine 41:1467-72.