Presentation is loading. Please wait.

Presentation is loading. Please wait.

The Febrile Returning Traveller

Similar presentations


Presentation on theme: "The Febrile Returning Traveller"— Presentation transcript:

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

2 Background Fever is most common reported symptom1,2 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: 2 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) MD Plan – ditto for other symptoms / may change from region – depending on disease profile

4 622 patients returning from the tropics3
Prospective European Study of 622 patients attending Travel Clinic Physicians after returning from tropics = 230 (36.1%) related to tropical diseases – incl. malaria, shistosomiases, amoebiasis, GE nemotodes, Dengue fever. / Of all febrile patients 54 (21%) were diagnosed with malaria / Significant 392 (63%) with non-related travel illness 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: Public Health & Safety:
Exclude first! 2. Exclude common life threatening tropical infections 3. Non-traveller infections 4. Non Infective causes 5. Specific geographical infections SAFE ?DANGER Malaria always 1st irrespective of precautions taken / Plasmodium Falcipurum responsible for 95% of malaria in Africa

6 Geographical pitfalls
Malaria endemicity may change rapidly Fringe malaria areas7 (seasonal & climate change) Rare cases of airport malaria8 BOTTOM LINE – ALWAYS EXLUDE MALARIA FIRST Expand / Careful, especially when you work in developed countries 7. Jelinek T, Corachan M, Grobusch M, et al. Falciparum Malaria in European Tourist to the Dominican Republic..Emerg Infect Dis 2000; 6: 8. Frean J, Blumberg L. Odyssean and non-mosquito-transmitted forms of malaria. Traveler's Malaria. 2nd ed., 2008:

7 Orange – rainfall & seasonal prone
Sossusvlei – Namib dessert – malaria cases in summer (highest rainfall)

8 Sossusvlei Namib Dessert
Map of Sossusvlei – winter & summer ALWAYS 2007/2008

9 High Risk Groups Children < 5yrs
Not always protected (Chemical & Physical) Non specific symptoms – fever, lethargy, malaise Risk of fever complications / severe malaria / cerebral malaria4,5 2. Pregnant woman 3. Elderly 4. Immunocompromised 5. Inhabitants of Endemic Areas whom emigrate loose their immunity within 6/12 after absence of re-exposure6 High risk for severe malaria with increased morbidity & mortality These 5 groups need to be hospitalized until malaria diagnosis are excluded 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 Box 1: Criteria for diagnosing severe Plasmodium Falciparum Malaria
Boggild, A. K. et al. CMAJ 2009;180: Copyright ©2009 Canadian Medical Association or its licensors

11 Malaria Fever Characteristics
80-90% of Malaria associated with fever4,5 Malaria naïve traveller – fever at lower parasitic count Partial immunity (repeat infections) fever at higher threshold parasitic count (flu like symptoms + d & v9,10) Fever as lead symptom is often irregular at onset , particularly in Falciparum malaria4 90% of Symptoms present within 1/12 of return1,5 EXCEPTIONS if patient taken chemoprophylaxis if P. Vivax & Ovale P Vivax months to years 9. Grobusch M, Kremsner P. Uncomplicated Malaria.Curr Topics Microbiol Immunol 2005; 295: 10. Jelinek T, Schulte C, Behrens R,et al. Imported Falciparum malaria in Europe. Clin Infect diseases 2002; 34:

12 Malaria diagnosis6 CLINICAL GOLD STD Giemsa stained thick & thin smear
REPEAT x3; 12h’ly X 24/48h11,12 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 Histadine rich protein; add photo – ltd. not quantitive / not suited for patient review / no ID of risk factors – ex. Malaria pigment containing leucocytes; no id of alternative infective agents ; add malaria smear / Treatment – Cloroquin resistant areas – Arthometisinin or Quinine + Doxycyline / X3 – admit while you repeat Grobusch M, Burchard G. Diagnosis of malaria in returned travellers. Traveller’s Malaria. 2nd 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: Public Health Safety:
1. Exclude malaria first! 2. Exclude common life threatening tropical infections 3. Non-traveller infections 4. Non Infective causes 5. Specific geographical infections SAFE ?DANGER Top 10 for your EC

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 Primary infection HIV

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

16

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
? Frequent traveler / If fever >21 days after return – unlikely to be Dengue Fever, other arbo viral infections, Rickettsial infections

19 Associated symptoms in the returning febrile traveler
Rash & history of swimming in fresh water – katakana fever / Rose rash & relative bradicardia – Typhoid / Chancre of Tsetsefly bite (Trypanosomiasis) vs.tascha noire (eshar) of tick bite fever+ LN & Rash (involving palms & soles)

20 Diagnosis confirmed by: Dengue IgG or IgM sero-conversion (>4) False positive: Yellow Fever Japanese Encephalitis inoculations Dengue Fever Non specific – flu like + fever + rash + arthritis / x4 different sero types

21 African Trypanosomiasis
East Africa Aggressive Tsetse fly bite – Chancre Fulminating illness – DIC Diagnosis – Blood Trypanosomes (Notify lab – scattered therefore easily missed) Trypanosoma Brucei Gambience – Chronic / Rhodiense – Acute /Myocarditis + coag disorder & DIC + CNS involvement/ Rx Suramin + Metasprorol (CNS involvement) – toxic – ICU – expert RX

22 Typhoid Fever More common in North Africa & India
Diagnosis: Clinical & Blood + Stool cultures Serology lacks specificity Widal test non-specific & often falsely positive Fever, rash, gradual onset head ache, rosesports , bradicardia & non specific abdo symptoms (even constipation) / Serology only helps if patient received earlier antibiotics /

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%13 Acute Presentation Shistosomiasis / Closely mimic malaria / 4 to 6/52 post exposure / serology to late – only assist as baseline test / Rx high dose steroids – Parziquentel may worsen symptoms(always steroid cover) 13. 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 Eshar / macular papular rash (including palms & soles) / Regional Lymphadenopathy / headache / fever

25 FRT - THINK PROCESS Step Approach: Public Health Safety:
1. Exclude malaria first! 2. Exclude common life threatening tropical infections 3. Non-traveller infections 4. Non Infective causes 5. Specific geographical infections 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 URT17 Similar organisms as non-travellers but increased proportion of atypical infections18,19 Spelunking – think Histoplasmosis Helmintic infections - larva migration in lungs - hypersensitivity reaction (eosinophilia may aid14,19) Atypical +legionnaires, viral pneumonia / Loffler syndrome – pulmonary infiltrate + cough + eosinophylia 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: 15. 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: 16. Hill D. Health problems in a large cohort of Americans traveling to developing countries. J Travel Med 2007;7: 17. Looke D, Robson J. Infections in the returned traveler. Med J Aust 2002;17:212-9. 18. Humar A, Keystone J. Evaluating fever in travellers returning from tropical countries. BMJ 1996;312: 19. Ryan E, Wilson M, Kain K. Illness after international travel. N Engl J Med 2002;347:505-6.

27 FRT - THINK PROCESS Step Approach: Public Health Safety:
1. Exclude malaria first! 2. Exclude common life threatening tropical infections 3. Non-traveller infections 4. Non Infective causes 5. Specific geographical infections 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: Public Health Safety:
1. Exclude malaria first! 2. Exclude common life threatening tropical infections 3. Non-traveller infections 4. Non Infective causes 5. Specific geographical infections 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 Treatment DEC – Di Ethyl Carbamazine ; Filariasis

31 Thank You


Download ppt "The Febrile Returning Traveller"

Similar presentations


Ads by Google