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The Febrile Returning Traveller Dr. Hein Lamprecht – Emergency Medicine Physician: SUN & UCT.

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Presentation on theme: "The Febrile Returning Traveller Dr. Hein Lamprecht – Emergency Medicine Physician: SUN & UCT."— Presentation transcript:

1 The Febrile Returning Traveller Dr. Hein Lamprecht – Emergency Medicine Physician: SUN & UCT

2 Background Fever is most common reported symptom 1,2 in the returning traveller acquired illness 1. Wilson M, Weld L, Boggild A, et al. Fever in returned travellers: results from GeoSentinel Surveillance Network. Clin Infect Dis 2007;44: Freedman D, Weld L, Kazarsky P, et al. Spectrum of disease and relation to place of exposure among ill returned travellers. N Engl J Med 2006;354:

3 Objectives Overview of a general EC/ED approach to fever in the returned traveller Not to explore countless causes of fever but to highlight aspects which can aid & facilitate diagnostic process (therapeutic options are not discussed)

4 622 patients returning from the tropics 3 3. Ansart S, Perez L, Vergely O, et al. Illness in travellers returning from the tropics: a prospective study of 622 patients. J of Travel Med;2007;12:

5 FRT - THINK PROCESS Step Approach: 1.Exclude first! 2.Exclude common life threatening tropical infections 3.Non-traveller infections 4.Non Infective causes 5.Specific geographical infections Public Health & Safety: SAFE ?DANGER SAFE ?DANGER

6 Geographical pitfalls Malaria endemicity may change rapidly -Fringe malaria areas 7 (seasonal & climate change) -Rare cases of airport malaria 8 BOTTOM LINE – ALWAYS EXLUDE MALARIA FIRST 7. Jelinek T, Corachan M, Grobusch M, et al. Falciparum Malaria in European Tourist to the Dominican Republic..Emerg Infect Dis 2000; 6: Frean J, Blumberg L. Odyssean and non-mosquito-transmitted forms of malaria. Traveler's Malaria. 2 nd ed., 2008:

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8 Sossusvlei Namib Dessert ALWAYS2007/2008

9 High Risk Groups 1.Children < 5yrs Not always protected (Chemical & Physical) Non specific symptoms – fever, lethargy, malaise Risk of fever complications / severe malaria / cerebral malaria 4,5 2.Pregnant woman 3.Elderly 4.Immunocompromised 5.Inhabitants of Endemic Areas whom emigrate loose their immunity within 6/12 after absence of re-exposure 6 4.Boggild A, Kain K. Malaria: Clinical features, management and prevention. International encyclopedia of public health. Vol.5: Academic Press; 2008.p Suh K, Kain K, Keystone J. Malaria. CMAJ 2004;170: Mascarello M, Allegranzi B, Angheben A, et al. Imported malaria in adults & children: epidemiological & clinical characteristics of 380 consecutive case observed in Verona, Italy. J Travel Med 2008;15:

10 Copyright ©2009 Canadian Medical Association or its licensors Boggild, A. K. et al. CMAJ 2009;180: Box 1: Criteria for diagnosing severe Plasmodium Falciparum Malaria

11 Malaria Fever Characteristics 80-90% of Malaria associated with fever 4,5 Malaria naïve traveller – fever at lower parasitic count Partial immunity (repeat infections) fever at higher threshold parasitic count (flu like symptoms + d & v 9,10 ) Fever as lead symptom is often irregular at onset, particularly in Falciparum malaria 4 90% of Symptoms present within 1/12 of return 1,5 EXCEPTIONSif patient taken chemoprophylaxis if P. Vivax & Ovale 9. Grobusch M, Kremsner P. Uncomplicated Malaria.Curr Topics Microbiol Immunol 2005; 295: Jelinek T, Schulte C, Behrens R,et al. Imported Falciparum malaria in Europe. Clin Infect diseases 2002; 34:

12 Malaria diagnosis 6 CLINICAL GOLD STD Giemsa stained thick & thin smear REPEAT x3; 12h’ly X 24/48h 11,12 Novel Laboratory Gold STD PCR – no role in emergency diagnosis of malaria Ag detection tests (in SA HRP2) – only P. Falciparum Clinical Clues:  Platelets (rare bleeding unless complicated malaria, ex. DIC)  Spleen size 11. Grobusch M, Burchard G. Diagnosis of malaria in returned travellers. Traveller’s Malaria. 2 nd ed.2008: Newman R, Parise M, Barber A, et al. Malaria related deaths amongst US travellers, Ann Int Med 2004;141:

13 FRT - THINK PROCESS Step Approach: 1.Exclude malaria first! 2.Exclude common life threatening tropical infections 3.Non-traveller infections 4.Non Infective causes 5.Specific geographical infections Public Health Safety: SAFE ?DANGER SAFE ?DANGER

14 Potential life threatening tropical infections Viral- Hemorrhagic Fever (region dependant) - Prodrome Viral hepatitis A,B & E - HIV - Cosmopolitan viral infections (Avian & H1N1) Bacterial- Typhoid Fever - TB Parasites- Malaria - Katayama fever - Trypanosomiasis Rickettsia- Rickettsia Africae

15 ACTION = COMPREHENSIVE ASSESMENT History (including: Travel Questionnaire) Thorough Physical examination Baseline Special Investigations plus clinically guided additional tests

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17 Special Investigations Haematology- FBC - Thick & Thin smear (REPEAT) - Coagulation MCS- Blood/Fecal/Urine Biochemistry & LFT - U&E / Transaminases Malaria Ag test Imaging - CXR & Liver Ultrasound

18 Incubation periods of travel related infections in febrile travellers

19 Associated symptoms in the returning febrile traveler

20 Dengue Fever Diagnosis confirmed by: Dengue IgG or IgM sero-conversion (>4) False positive: Yellow Fever Japanese Encephalitis inoculations

21 African Trypanosomiasis East Africa Aggressive Tsetse fly bite – Chancre Fulminating illness – DIC Diagnosis – Blood Trypanosomes (Notify lab – scattered therefore easily missed)

22 Typhoid Fever More common in North Africa & India Diagnosis: Clinical & Blood + Stool cultures Serology lacks specificity Widal test non-specific & often falsely positive

23 Katayama Fever Clinical Diagnosis (negative Malaria) Serology only positive 3/12 post exposure Positive ova in urine only 45 days post exposure 1 day absolute risk swimming in Lake Malawi of acquiring Shistosomiasis 52%-74% D’Acremont V, Burnard B, Ambresin A, et.al. Practice guidelines for the evaluation of fever in the returning traveler. J Travel Med 2003;10 Suppl 2:S25-S45.

24 Rickettsia Africae Clinical Diagnosis Serology only turns converts only 7 days after exposure Weil-Felix – poor sensitivity & specificity

25 FRT - THINK PROCESS Step Approach: 1.Exclude malaria first! 2.Exclude common life threatening tropical infections 3.Non-traveller infections 4.Non Infective causes 5.Specific geographical infections Public Health Safety: SAFE ?DANGER SAFE ?DANGER

26 3. Non-travel infections Most common – RTI & UTI 20-40% 14,15,16 of RT’s have respiratory symptoms upon their return, most common allergies & viral infections of URT 17 Similar organisms as non-travellers but increased proportion of atypical infections 18,19 Spelunking – think Histoplasmosis Helmintic infections - larva migration in lungs - hypersensitivity reaction (eosinophilia may aid 14,19 ) 14.Freedman D, Weld L, Kozarsky P, et al. GeoSentinel Surveillance Network. Spectrum of disease & relation to place of exposure amongst ill returned travellers. New Engl Jour of Med 2006;354: O’Brain D, Tobin S, Brown G, et al. Fever in returned travellers: review of hospital admissions for 3 year period. Clin Infect Dis 2001;33: Hill D. Health problems in a large cohort of Americans traveling to developing countries. J Travel Med 2007;7: Looke D, Robson J. Infections in the returned traveler. Med J Aust 2002;17: Humar A, Keystone J. Evaluating fever in travellers returning from tropical countries. BMJ 1996;312: Ryan E, Wilson M, Kain K. Illness after international travel. N Engl J Med 2002;347:505-6.

27 FRT - THINK PROCESS Step Approach: 1.Exclude malaria first! 2.Exclude common life threatening tropical infections 3.Non-traveller infections 4.Non Infective causes 5.Specific geographical infections Public Health Safety: SAFE ?DANGER SAFE ?DANGER

28 4. Non Infective causes Social Drugs / Medications Drug Interactions Inflammatory causes Malignancy (Lymphoma / Leukemia) Rheumatological Pulmonary Embolism Thyrotoxicosis

29 FRT - THINK PROCESS Step Approach: 1.Exclude malaria first! 2.Exclude common life threatening tropical infections 3.Non-traveller infections 4.Non Infective causes 5.Specific geographical infections Public Health Safety: SAFE ?DANGER SAFE ?DANGER

30 5. Geographical infections Example: Loa Loa disease (African eye worm) Location:West Africa rain forests Vector: Crysops fly Reservoir: Human Clinical: Eye & skin – calabar swelling Diagnosis:Microfilaria on Giemsa Stained Blood smear & microscopy

31 Thank You


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