fever in the returning traveller part ii dr viviana elliott consultant acute medicine
TRANSCRIPT
Fever in the returning traveller Part II
Dr Viviana Elliott
Consultant Acute Medicine
Viral haemorrhagic Fever
Lassa fever RARE!!!
Only VHF reported inUK
Dengue
Others Ebola
Marburg
Yellow fever
Malaria: Plasmodium falciparum
5000 x common than Lassa fever!!!!!
Fever, rural area, likely contact, high fever ,
severe exudative sore throat, prostration out
of proportion with fever
Malaria• Should be thought in febrile illness in travellers
returning to Europe from tropic
Sub - Saharan Africa
Malaria
Early diagnosis and assessment of severity is vital to avoid deathsSymptoms are non specific
Almost 50% are a febrile on presentation but all have history of fever
Consider country of travel, stopovers and date of return. Incubation: at least 6 days and within 3 months more with prophylaxis
Consider other infections: Typhoid fever, hepatitis, dengue fever, avian influenza, SARS, HIV, Meningitis, Encephalittis and VHF
Urgent investigations
• Thick (find it) and thin (typify it) and rapid antigen test ( less sensitive for non falciparum, no info about parasite count, maturity or mixed species. Use in adjunct with microscopy)
• FBC: Thrombocytopenia, U&Es, LFT and
GLUCOSE
• BCM for typhoid and other bacteriemia
• Urine dipstick for haemoglobinuria and culture. Stool culture if diarrhoea
• CXR to r/o CAP
La
Laboratory diagnostic approach Diagnostic Approach
↑WBC with neutrophils ↓ WBC with neutrophils ↓ WBC with lymphocytes
Pneumonia UTILeptospirosisBrucella
TyphoidOther Salmonella
ViralRickettsial
FBC
Eosinophils: helminth, drugs. Unlikely bacterial
Very High High bili + Mod trans + Renal disfunction
Viral hepatitis Yellow feverToxin
Leptospirosis
LFTs
Falciparum Malaria or mixed infection
Admit all cases and assess severity
Complicated Malaria
Treatment
Enteric Fever(Typhoid and Paratyphoid))
• Commonest serious tropical disease from Asia
• Distribution: worldwide in developing countries
• Asia and south east Asia
>100 cases per 100.000 person per year
77% in person visiting friends and family
• Most cases occur 7 – 18 days after exposure
range 3-60 days
Clinical Presentation of Enteric Fever
Fever is almost invariable Relative bradycardia only first week
Clinical presentation of Enteric Fever
• Constipation more common than diarrhoea
initial loose stools fairly common
• Maybe evanescent rash: “Rose spots”
InvestigationsFirst Week:
Bloods: low WBC, platelets and mildly raised LFTs
BCM positive 40-80%
• Second week
Urine culture 0-58%
Stool culture 35-65%
Bone marrow higher sensitivity than BCM
• Newer rapid serology IgM against specific S Typhi
• Widal test lacks sensitivity and specificity Not recommended
Complications
• Incidence: 10-15%
illness >2 weeks
• GI Bleed
• Intestinal perforation
• Typhoid encephalopathy
Vaccination provides incomplete protection
Treatment• Unstable treat empirically pending BCM
• First choice: Ceftriaxone 2g iv
• 70% of isolated S typhi and paratyphi imported into Uk are resistant to Cipro
• In patients returning from Africa resistance 4%
• If resistance to Cipro, Azitromycin
• NOTE: fever take some time to respond regardless of antibiotic use failure to defervesce is not a reason to change antibiotics if sensitive
Rickettsia: Common infection in travellers to games parks in southern Africa
RicketssiasRickettsia Africae Conorii Typhi Orientia
Tsusugamuyi
African tickbite fever
Mediterranean spotted fever fever
Murine typhus Scrub typhus from Asia
Transission Catle ticks Dog tick Rat fleas Mites
Distribution Sub-saharan African and safari park in southern Africa Eastern Caribean
Mediterranean and Caspian Litoral, Middle East , Indian subcontinent and Africa
Tropical and subtropical areas in port cities where the rodent population is dense
Rural South Asia (Laos)South East AsiaWestern pacificInfrequently report by travellers
Complications Fatal 32% Fatal 2% If untreated:Pneumonitis, CID,ARF and Meningoencephalitis
Common presentation• Incubation: 5-7 days (up to 10 days)
• Non specific fever, head ache , mialgia, inoculation echar/rash and lymphadenitis
• Consider other causes of fever and skin lesions wich resembles echar:
Antrax
African Trypanosomiasis (chancre at site of tsetse fly bite)
R Africae: multiple
R Conorii: single
R Typhi
Investigations• Treatment should be started on suspicion :
- illness onset within 10 days
- exposure to tick in game park
- fever and headache with or without rash
• Doxycyxline 100 mg bd for 7 days or 48 hs after fever defervescence
• Confimation IFA paired initial and convalescence –phase serum sample
• If wider differential is considered: Cipro or Azithromycin
Arbovirus infection
• Commonest arboviral infection in returning travellers to the UK are Dengue and Chikungunya
• Incubation: 4 – 8 days (range 3-14)
• Distribution: Asia and south America
• Repoted >100 countries and annual global incidence 50-100 million per year
• Transmission: Aedes aegypty
Clinical presentation• Mild febrile illness
Headache- retro-orbital pain
Myalgia - arthralgia (> back pain)
Rash 1st erythrodermic
2nd petechial
Bleeding gums, epistaxis and GI bleed
Rarely hepatitis, myocarditis, encephalities
and neuropathies
Convalescence desquamation and post viral fatigue
Dengue
2 days later
Dengue diagnosis and treatment
• Positive PCR or if symptoms> 5-7 days +IgM ELISA
• Retrospective > 4 fold ↑ Ig G by haemoaglutination inhibition test
• UK reference laboratory services: HPA Special Pathogens reference Unit, Poton Down
• Treatment identify those patients at high risk of shock with daily FBC and platelets.
Acute Schistosomiasis
• Katayama fever
• Incubation: 4-6 weeks ( range 3-10 weeks)
• Distribution: Africa (Asia- South America)
• Transmission: Swimming in lakes or rivers
Cercariae release from snails penetrates intact skin
Clinical presentation
• Non specific signs and symptoms (? immune complex phenomenon)
fever myalgia arthralgia
lethargy cough/wheeze headache
rash ↑Liver/spleen diarrhoea
• Investigations:
eosinophilia
egg urine-stools
minority serology + seroconversion
0-6 months)
Treatment• Diagnosis:
Fresh water exposure 4-8 weeks previously
Fever-Urticarial rash-Eosinophilia
• Treatment empiric!!!!
• Praziquantel
2 doses 20 mg/kg, 4-6 hs apart (Mature Schistosomes)
Repeat after 3 months ( Immature schistosomes)
• Short course of Steroids may alleviate acute symptoms
Leptospirosis
• Distribution: Worldwide including UK
(> tropical and subtropical regions)
• Risk: exposure to fresh surface water, rodents (infected urine)
sports events
river rafting
rescue efforts after flooding
Leptospirosis clinical presentation
• Incubation : 7 – 12 days (range 2-30 days)
• Initial phase: “flu like symptoms” lasting 4-7 days
• Immune phase: “Weil’s disease”
1-3 days later
fever, myalgia (calves)
haepatorrenal syndrome
haemorrhages
Conjunctiva suffusions suggestive
Other manifestations
• GI: V-D, loss appetite, jaundice and hepatomegaly, liver failure, pancreatitis and GI bleed
• Respiratory: Cough + SOB
• Meningitis
• ARF
• Myocarditis
• Haemorrages – may confuse DHF
Investigations
• Urinalysis proteinuria/haematuria
• FBC PMN leucocytosis
Thrombocytopenia
Anaemia
• Clotting normal (capillary fragility)
• LFT high bili + mildly raised ALT
• U&Es ARF
• Serology IgM titre > 1:320 (early infection)
> 10 days after symptoms send for IgM ELISA+ Microscopic agglutination MAT to confirm diagnosis
Treatment
• Upon suspicion
• Penicillin and tetracycline antibiotics during bacteraemia phase
• Un well patients and Weil’s disease need renal and liver support
• Severe diseases is probably immunologically
mediated ( ? Benefit from antibiotics)
Amoebic Liver Abscess
• Incubation: 8-20 weeks ( up to a year)
• Distribution : Worldwide > developing countries
• Presentation: 67-98% Fever
72-95% Abdominal pain
43-93% Haepatomegaly
20% PMH dysentery
10% diarrhoea on diagnosis
Investigations• FBC neutrophil leucocytosis > 10 X 10 6 L
• LFT dearranged ↑↑ Alk Pho
• CRP/ESR raised
• Indirect haemagglutination >90% sensitivity
• Stoolsnegative
• CxR Raised hemi-diaphragm
• USS DD piogenic abscess (percutanous aspiration) R/O Hydatidic disease first!
Amoebic Liver abscess
Treatment• Start empiric treatment in patients with suggestive
history, epidemiology and imaging
• Metronidazole 500 mg tds orally for 7-10 days ( Cure in 90%)
• Tinidazole 2 g daily for 3 days (less nauseas)
• Follow treatment with 10 days luminal amoebicide to reduce relapse.
• Furoate 500 mg tds or Paromomycin 30 mg/kg per day in 3 divided doses
Brucellocis
• Incubation: 2-4 weeks (up to 6 months)
• Distribution: world-wide ( Middle East, URRS, Balkan Peninsula and Mediterranean basin)
• Transmission: infected unpasteurised milk products. Farmers, vets with contact infected parts.
Clinical presentation
• Fever Commonest presentation
acute with rigors or
chronic low grade relapsing
• Lymphadenopathy
• Hepatosplenomegaly
Complications:
• Osteoarticular disease
OA: knees, hips, ankles and wrists
Sacroillitis lumbar spine
Other complications
• Epididymo-orchitis
• Septic abortions
• Neurological: meningitis encephalitis brain abcess
• Endocarditis: Aortic valve and requires early surgery
Investigations and treatment
• LFT: mild transaminitis
• FBC: pancytopenia
• Bone marrow: gold standard
• BCM: sensitivity 15-70% (prolong cultures up to 4 weeks)
Note: Q Fever, rarer, similar from same area
Serology is key diagnosis!!
• Treatment: Doxycycline and Rifampicin 6-8 weeks + amynoglucosides 2 weeks
• Relapse 10 %
HIV
• Prevalence in tropical countries is high 1/3 sexually active population and not restricted to high-risk groups
• 5-51% travellers take part in casual sex while abroad
• HIV seroconversion and syphilis can present as febrile illness
Hepatitis
• Incubation: A 15-50 days
B 60-110 days
E 14-70 days
• Transmission A-E faecal-oral (water, food:shellfish and direct contact)
B sex-blood
Diagnosis IgM
Traetment Supportive
Fever an respiratory symptoms• Upper respiratory tract infection: viral, St.Pneumonia, H
Influenza, Grup A steptoccoi
Diphteria in traveller returning from URRS, India, South East Asia and South America
• Lower respiratory tract infections:
HIV related PCP
Bird flu
TB (prolonged visits to families and friends) Histoplasmosis/ Coccidioidomycosis risk activities with dust and bats in caves in America
Initial treatment for “bird flu”
• Isolate
Respiratory isolation ideally negative pressure
• Samples NPA & nasal swab PCR
• Inform
Local: ICT/Virology/ID
Regional: HPA/CCDC
• Treat: Oseltamivir/Zanamavir
Fever and Neurological Symptoms• 15 per 1000 ill returned travellers
• Most common: Malaria and meningitis
• Encephalopathy: P falciparum,typhoid and HIV seroconversion
• Encephalitis with or without fever
Common causes in UK +
Arboviruses Brucellosis
Rabies Rickettsias
African trypanosomiasis
Discussion with virologist or reference laboratory
Key points
• Think of the 5 Ws
• Risk factors for disease
• Don’t miss…
– HIV (risk group)
– TB (risk group)
– Malaria (knowledge of travel)
– Enteric fever (knowledge of travel)