Fever in the Fever in the TropicsTropics

Tom D. Thacher, MDTom D. Thacher, MDDepartment of Family MedicineDepartment of Family Medicine

Mayo Clinic, Rochester, MinnesotaMayo Clinic, Rochester, Minnesota

thacher.thomas@mayo.eduthacher.thomas@mayo.edu

Fever as a SymptomFever as a Symptom

1.1. MalariaMalaria

2.2. HypertensionHypertension

3.3. DyspepsiaDyspepsia

4.4. Pulmonary Pulmonary tuberculosistuberculosis

5.5. Medical Medical examinationexamination

6.6. Upper respiratory Upper respiratory infectioninfection

7.7. Urinary tract Urinary tract infectioninfection

8.8. HIV infectionHIV infection

9.9. Diabetes mellitusDiabetes mellitus

10.10.PIDPID

1/3 of all presentations in primary care1/3 of all presentations in primary care

Disease Burden by Region

0%

20%

40%

60%

80%

100%

Africa SE Asia Americas

Injuries

Non-communicable

Communicable

Learning ObjectivesLearning Objectives

1.1. Syndromic ApproachSyndromic Approach

2.2. 8 Febrile Syndromes8 Febrile Syndromes

Context of FeverContext of Fever• AgeAge

• GeographyGeography

• SeasonSeason

• Duration of feverDuration of fever

• MalnutritionMalnutrition

• Immune statusImmune status

• ExposuresExposures

Empiric treatmentEmpiric treatment

Syndromic ApproachSyndromic Approach

88CommonCommon

FeverFeverSyndromesSyndromes

1.1. Fever aloneFever alone

2.2. NeurologicNeurologic

3.3. AbdominalAbdominal

4.4. PulmonaryPulmonary

5.5. RashRash

6.6. HemorrhageHemorrhage

7.7. Bone and jointBone and joint

8.8. GynecologicGynecologic

Which of these is NOT in the top Which of these is NOT in the top five causes of death in children in five causes of death in children in

tropical countries?tropical countries?

A. B. C. D. E.

38%

14%

6%

19%22%

A.A. MeaslesMeasles

B.B. PneumoniaPneumonia

C.C. TyphoidTyphoid

D.D. HIVHIV

E.E. MalariaMalaria

Malaria21%

Pneumonia17%

Diarrhea12%

HIV9%

Measles8%

Perinatal15%

Other18%

Causes of Death in Children Under Age 5 Years in Africa

2/3 of all2/3 of allchild deathschild deaths

1.1. Fever AloneFever Alone

• MalariaMalaria

• Typhoid feverTyphoid fever

• HIVHIV

• DengueDengue

• LeptospirosisLeptospirosis

• RickettsiaRickettsia

• Relapsing feverRelapsing fever

• Other viral illnessesOther viral illnesses

Okie S. N Engl J Med 2008;358:2425-2428MalariaMalaria

Plasmodium falciparumPlasmodium falciparum

Symptoms of malariaSymptoms of malaria

• HeadacheHeadache

• PallorPallor• Severe hemolytic anemiaSevere hemolytic anemia• Heart failureHeart failure

• Cerebral malaria – impaired mental Cerebral malaria – impaired mental status, convulsions, comastatus, convulsions, coma

• Labored breathingLabored breathing• acidosis, heart failureacidosis, heart failure

• SplenomegalySplenomegaly

Typhoid FeverTyphoid Fever

TyphoidTyphoid

• Sustained high Sustained high fever, headachefever, headache

• Apathy, psychosisApathy, psychosis

• Constipation, Constipation, abdominal painabdominal pain

• SplenomegalySplenomegaly

• Positive blood Positive blood cultureculture

www.worldortho.med.usyd.edu.au www.worldortho.med.usyd.edu.au

DengueDengue

• Asia, So. AmericaAsia, So. America

• Marked myalgia, eye painMarked myalgia, eye pain

• RashRash

• ↓ ↓ WBC, ↓ plateletsWBC, ↓ platelets

LeptospirosisLeptospirosis

• RashRash

• Aseptic meningitisAseptic meningitis

• Clue: conjunctival injection Clue: conjunctival injection

RickettsiaRickettsia

• Fever, headache, and myalgia Fever, headache, and myalgia

• Clue: tick exposure, painless escharClue: tick exposure, painless eschar

• African tick-bite fever, scrub typhusAfrican tick-bite fever, scrub typhus

Relapsing FeverRelapsing Fever

88CommonCommon

FeverFeverSyndromesSyndromes

1.1. Fever aloneFever alone

2.2. NeurologicNeurologic

3.3. AbdominalAbdominal

4.4. PulmonaryPulmonary

5.5. RashRash

6.6. HemorrhageHemorrhage

7.7. Bone and jointBone and joint

8.8. GynecologicGynecologic

2.2. Neurologic SyndromesNeurologic Syndromes

Fever, headache, altered mental Fever, headache, altered mental status, convulsions, comastatus, convulsions, coma

• Cerebral malariaCerebral malaria

• MeningitisMeningitis

• EncephalitisEncephalitis

• HIVHIV

African Meningitis BeltAfrican Meningitis Belt

EncephalitisEncephalitis

• RabiesRabies

• Japanese encephalitisJapanese encephalitis

• West Nile encephalitisWest Nile encephalitis

• Trypanosomiasis (sleeping sickness)Trypanosomiasis (sleeping sickness)

HIVHIV

• Chronic Meningitis: TB, cryptococcalChronic Meningitis: TB, cryptococcal

• ToxoplasmosisToxoplasmosis

• HIV dementiaHIV dementia

88CommonCommon

FeverFeverSyndromesSyndromes

1.1. Fever aloneFever alone

2.2. NeurologicNeurologic

3.3. AbdominalAbdominal

4.4. PulmonaryPulmonary

5.5. RashRash

6.6. HemorrhageHemorrhage

7.7. Bone and jointBone and joint

8.8. GynecologicGynecologic

3.3. Abdominal SyndromesAbdominal Syndromes

Fever, abdominal painFever, abdominal pain

• TyphoidTyphoid

• Infectious colitis: shigella, E. coli, Infectious colitis: shigella, E. coli, salmonella, campylobacter, amebasalmonella, campylobacter, ameba

• Amebic liver abscessAmebic liver abscess

• Abdominal TBAbdominal TB

• Appendicitis, pyelonephritisAppendicitis, pyelonephritis

• HIVHIV

88CommonCommon

FeverFeverSyndromesSyndromes

1.1. Fever aloneFever alone

2.2. NeurologicNeurologic

3.3. AbdominalAbdominal

4.4. PulmonaryPulmonary

5.5. RashRash

6.6. HemorrhageHemorrhage

7.7. Bone and jointBone and joint

8.8. GynecologicGynecologic

4.4. Pulmonary SyndromesPulmonary Syndromes

Fever, cough, dyspneaFever, cough, dyspnea

• PneumoniaPneumonia

• TuberculosisTuberculosis

• HIVHIV

Malaria21%

Pneumonia17%

Diarrhea12%

HIV9%

Measles8%

Perinatal15%

Other18%

Causes of Death in Children Under Age 5 Years in Africa

IMCIIMCIIntegrated Management of Childhood IllnessIntegrated Management of Childhood Illness

• Increased respiratory rateIncreased respiratory rate• ≥≥60 if age < 2 mos.60 if age < 2 mos.• ≥≥50 if age 2-12 mos.50 if age 2-12 mos.• ≥≥40 if age 12 mos. to 5 years40 if age 12 mos. to 5 years

• Lower chest retractionsLower chest retractions

88CommonCommon

FeverFeverSyndromesSyndromes

1.1. Fever aloneFever alone

2.2. NeurologicNeurologic

3.3. AbdominalAbdominal

4.4. PulmonaryPulmonary

5.5. RashRash

6.6. HemorrhageHemorrhage

7.7. Bone and jointBone and joint

8.8. GynecologicGynecologic

5.5. Rash SyndromesRash Syndromes

Fever and skin rashFever and skin rash

• MeaslesMeasles

• HIVHIV

• DengueDengue

• Other virusesOther viruses

88CommonCommon

FeverFeverSyndromesSyndromes

1.1. Fever aloneFever alone

2.2. NeurologicNeurologic

3.3. AbdominalAbdominal

4.4. PulmonaryPulmonary

5.5. RashRash

6.6. HemorrhageHemorrhage

7.7. Bone and jointBone and joint

8.8. GynecologicGynecologic

6.6. Hemorrhagic SyndromesHemorrhagic SyndromesHematemesis, melena, epistaxis, petechiae, Hematemesis, melena, epistaxis, petechiae,

purpura, puncture site bleedingpurpura, puncture site bleeding

• Ebola, Lassa, MarburgEbola, Lassa, Marburg

• Yellow feverYellow fever

• DengueDengue

• Relapsing feverRelapsing fever

88CommonCommon

FeverFeverSyndromesSyndromes

1.1. Fever aloneFever alone

2.2. NeurologicNeurologic

3.3. AbdominalAbdominal

4.4. PulmonaryPulmonary

5.5. RashRash

6.6. HemorrhageHemorrhage

7.7. Bone and jointBone and joint

8.8. GynecologicGynecologic

7.7. Musculoskeletal SyndromesMusculoskeletal Syndromes

Fever with joint or bone painFever with joint or bone pain

• Sickle cell diseaseSickle cell disease

• Septic arthritisSeptic arthritis

• OsteomyelitisOsteomyelitis

• PyomyositisPyomyositis

• Rheumatic feverRheumatic fever

88CommonCommon

FeverFeverSyndromesSyndromes

1.1. Fever aloneFever alone

2.2. NeurologicNeurologic

3.3. AbdominalAbdominal

4.4. PulmonaryPulmonary

5.5. RashRash

6.6. HemorrhageHemorrhage

7.7. Bone and jointBone and joint

8.8. GynecologicGynecologic

8.8. Gynecologic SyndromesGynecologic Syndromes

Fever, pelvic pain, vaginal Fever, pelvic pain, vaginal dischargedischarge

• PIDPID

• Tubo-ovarian abscessTubo-ovarian abscess

• Postpartum endometritisPostpartum endometritis

• Septic abortionSeptic abortion

Treatment Limiting FactorsTreatment Limiting Factors

• Self treatment with OTC antibioticsSelf treatment with OTC antibiotics

• Limited spectrum of antibioticsLimited spectrum of antibiotics

• No health insuranceNo health insurance

• Counterfeit drugs and adulterationCounterfeit drugs and adulteration

What is the What is the deadliest animal deadliest animal

in Africa?in Africa?

no-pest.comno-pest.com

no-pest.comno-pest.com

news.nationalgeographic.comnews.nationalgeographic.com

20,000 deaths per year20,000 deaths per year

800,000 deaths per year800,000 deaths per year