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Evaluation of Illness in the Returned Traveler Jean Haulman MD Hall Health Primary Care Center University of Washington ACHA May 27, 2008.

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Presentation on theme: "Evaluation of Illness in the Returned Traveler Jean Haulman MD Hall Health Primary Care Center University of Washington ACHA May 27, 2008."— Presentation transcript:

1 Evaluation of Illness in the Returned Traveler Jean Haulman MD Hall Health Primary Care Center University of Washington ACHA May 27, 2008

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3 Your favorite exotic disease is only an airplane ride away

4 About 30 million Americans go abroad each year 8 million will go to less developed countries 8 million will go to less developed countries 7 million will go where there is risk of malaria 7 million will go where there is risk of malaria 223,000 American university students studied abroad in ,000 American university students studied abroad in European destinations remained flatEuropean destinations remained flat Study in less developed countries roseStudy in less developed countries rose Middle East up 31%Middle East up 31% Asia up 26%Asia up 26% Latin America up 14%Latin America up 14%

5 International Destinations of Americans (2004) 43% Traveled to Europe 43% Traveled to Europe 19% to Asia 19% to Asia 18% Islands in the Caribbean 18% Islands in the Caribbean 16% Central and South America 16% Central and South America 4% Middle East 4% Middle East 3% Oceania 3% Oceania 2% Africa 2% Africa Source: US Department of Commerce

6 True risk Traffic accidents (exotic and non-exotic) remain the leading cause of death in foreign travelers

7 Most Common Illness in Returned Travelers Diarrhea: 46% Diarrhea: 46% Travelers’ diarrhea 34%Travelers’ diarrhea 34% Respiratory Illness: 26% Respiratory Illness: 26% Skin problems: 8% Skin problems: 8% Acute mountain sickness: 8% Acute mountain sickness: 8% Motion sickness: 5% Motion sickness: 5% Isolated febrile illness: 3% Isolated febrile illness: 3%

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9 DIARRHEA A.K.A. Montezuma’s revenge Aztec two-step The trots Turkey Trots Turista

10 Distribution of TD

11 Why is diarrhea more common in the developing world?

12 Travelers’ diarrhea Risk increases in travelers going to less developed country Risk increases in travelers going to less developed country Food is the vector for travelers’ diarrhea more often than water Food is the vector for travelers’ diarrhea more often than water

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14 Travelers’ diarrhea >/= 3 or more unformed stools in 24 hours >/= 3 or more unformed stools in 24 hours Associated with N, V, T, cramps, urgency Associated with N, V, T, cramps, urgency Usually an acute, self-limiting illness; resolves within about 5 days. Usually an acute, self-limiting illness; resolves within about 5 days. 3-10% of pts with TD will have symptoms lasting longer than 2 weeks. 3-10% of pts with TD will have symptoms lasting longer than 2 weeks. Up to 3% of travelers have diarrhea lasting over 30 days, some long term Up to 3% of travelers have diarrhea lasting over 30 days, some long term Most symptoms occur while abroad Most symptoms occur while abroad

15 Self-treatment for bacteria associated with TD Most of the world: Most of the world: ETEC (enterotoxigenic E. coli)ETEC (enterotoxigenic E. coli) Self-treatment: fluoroquinoloneSelf-treatment: fluoroquinolone Southeast Asia: Southeast Asia: FQ-resistant Campylobacter.FQ-resistant Campylobacter. Self-treatment: macrolideSelf-treatment: macrolide

16 Persistent infection with bacterial pathogens Bacterial infections damage intestinal mucosa Bacterial infections damage intestinal mucosa Days to weeks to repair after clearance of organism Days to weeks to repair after clearance of organism May take up to a month to return to normal bowel habits post infection with Campylobacter, Yersinia, Enteroadherent E. coli May take up to a month to return to normal bowel habits post infection with Campylobacter, Yersinia, Enteroadherent E. coli

17 Etiologies of Chronic TD Infectious Infectious bacteriabacteria virusesviruses parasitesparasites Non-infectious Non-infectious Malabsorptive syndromesMalabsorptive syndromes

18 Bacterial causes of chronic TD Enterotoxigenic E. coli (ETEC) Enterotoxigenic E. coli (ETEC) Enteroadherent E. coli (EAEC) Enteroadherent E. coli (EAEC) Campylobacter Campylobacter Shigella Shigella Salmonella Salmonella (Yersenia, Vibrio cholera, Vibrio parahemalyticas) (Yersenia, Vibrio cholera, Vibrio parahemalyticas)

19 Protozoal causes of chronic TD Giardia lamblia Giardia lamblia Entamoeba histolytica Entamoeba histolytica Cyclospora cayentanensis Cyclospora cayentanensis Cryptosporidium Cryptosporidium Dientamoeba fragilis Dientamoeba fragilis Microsporidia Microsporidia

20 Labs for diarrhea Labs for diarrhea Do nothing if diarrhea is mild and present less than 5-7 daysDo nothing if diarrhea is mild and present less than 5-7 days Stool O&P + Giardia AgStool O&P + Giardia Ag Stool C&S x 1Stool C&S x 1 Stool C. difficile if history of antibiotic or antimalarial useStool C. difficile if history of antibiotic or antimalarial use CBC with diffCBC with diff U/AU/A

21 Laboratory work-up If symptoms are mild and duration is less than one week, there is no need to order labs.

22 In long-term ex-pats with GI sx, consider tropical sprue Poorly characterized syndrome of worsening intestinal symptoms with continuing diarrhea and steatorrhea Poorly characterized syndrome of worsening intestinal symptoms with continuing diarrhea and steatorrhea Occurs in ex-pats living long-term (over one year) and residents of tropical and sub-tropical areas. (Caribbean, southern India, and SE Asia: From 30 N. of equator to 30  South.) Occurs in ex-pats living long-term (over one year) and residents of tropical and sub-tropical areas. (Caribbean, southern India, and SE Asia: From 30 N. of equator to 30  South.) Rare in short-term travelers. Rare in short-term travelers. Etiology: unknown Etiology: unknown

23 Tropical sprue (cont.) Sx: light-colored stools, weight loss, chronic diarrhea. Sx: light-colored stools, weight loss, chronic diarrhea. Iron, B12 and folic acid deficiency anemia. Iron, B12 and folic acid deficiency anemia. Prothrombin deficiencyeasy bruising, prolonged bleeding. Prothrombin deficiencyeasy bruising, prolonged bleeding. Small intestine biopsy: flattened villi. Small intestine biopsy: flattened villi.

24 Tropical sprue (cont.) Treatment: most patients improve with tetracycline x several months + vitamin B12 and folic acid. Treatment: most patients improve with tetracycline x several months + vitamin B12 and folic acid. Treatment usually results in full recovery. Treatment usually results in full recovery.

25 Post-infectious malabsorption A.k.a. post-infectious dysmotility syndrome, post-infectious irritable bowel syndrome. A.k.a. post-infectious dysmotility syndrome, post-infectious irritable bowel syndrome. A common sequelae of TD. A common sequelae of TD. A diagnosis of exclusion. A diagnosis of exclusion. Usually self-limiting. Usually self-limiting. Can evolve into permanent irritable bowel syndrome. Can evolve into permanent irritable bowel syndrome.

26 TD Pearls Not all diarrhea that begins during or immediately after international travel is related to that travel. Not all diarrhea that begins during or immediately after international travel is related to that travel. No positive lab findings  “You’re fine.” No positive lab findings  “You’re fine.” P. falciparum can present as diarrhea and fever. P. falciparum can present as diarrhea and fever.

27 Travelers want to spend time here

28 --not here--

29 Fever and Illness in the returned traveler 2-3% of international travelers develop fever during or immediately after their trip.

30 Fever in the Returned Traveler The differential diagnosis of fever in the returned traveler is LARGE The differential diagnosis of fever in the returned traveler is LARGE The diagnoses accounting for most of the causes of fever is small The diagnoses accounting for most of the causes of fever is small

31 Most common cause of fever in the returned traveler Malaria 27-42% Malaria 27-42% URI/LRI3-24% URI/LRI3-24% Diarrhea/dysentery 5-14% Diarrhea/dysentery 5-14% Dengue2-8% Dengue2-8% Hepatitis (us. A)3-6% Hepatitis (us. A)3-6% UTI 2-4% UTI 2-4% Typhoid fever2-3% Typhoid fever2-3%

32 Non Infectious Sources of Fever DVT, PEDVT, PE Serum sicknessSerum sickness MalignancyMalignancy Collagen Vascular DiseaseCollagen Vascular Disease

33 Finding the diagnostic possibilities… / acatalog/On_line_Gallery_R...

34 …can be challenging

35 How to approach the evaluation of the ill, often febrile, returned traveler systematically Remember all fever in returning traveler from endemic country is malaria until proven otherwise AND all patients seen with fever in developing countries have a good chance of being treated for malaria

36 History Destination country, season Destination country, season Exposure history: planned activities, accommodations, food, water, swimming holes, new sexual partner, etc Exposure history: planned activities, accommodations, food, water, swimming holes, new sexual partner, etc Incubation period: when did fever or symptoms start? Incubation period: when did fever or symptoms start? Pre-travel vaccinations and malaria meds Pre-travel vaccinations and malaria meds General health and immune system status General health and immune system status

37 Characteristic Findings Physical Physical Vital signsVital signs Skin findings including bite marksSkin findings including bite marks Joint, Respiratory, GI, Neuro SxsJoint, Respiratory, GI, Neuro Sxs Labs Labs EosinophiliaEosinophilia Leukopenia, ThrombocytopeniaLeukopenia, Thrombocytopenia LFTsLFTs

38 1. Travel location(s) and duration of stay The longer the stay in a developing country the greater the risk of travel related illness The longer the stay in a developing country the greater the risk of travel related illness Short stays are considered <2-3 weeks Short stays are considered <2-3 weeks Long stays are > 1 month Long stays are > 1 month The destination may include or exclude certain illness that follow geographic patterns and seasons The destination may include or exclude certain illness that follow geographic patterns and seasons

39 Yellow Fever

40 Meningococcal Infections

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44 2. Accommodations Accommodations Accommodations Accommodations: Hotel, tent, hostel, caveAccommodations: Hotel, tent, hostel, cave City vs. ruralCity vs. rural

45 Activities/ Accommodations Reason for travel Reason for travel backpacking,backpacking, Hiking/ trekkingHiking/ trekking spelunkingspelunking Caves Caves rabies (bat bite, or bat guano inhalation)rabies (bat bite, or bat guano inhalation) HistoplasmosisHistoplasmosis

46 Accommodations Crowded living conditions, group travel, exposure to ill persons: Crowded living conditions, group travel, exposure to ill persons: Meningococcal diseaseMeningococcal disease InfluenzaInfluenza TuberculosisTuberculosis VHFS: Lassa, Marburg, EbolaVHFS: Lassa, Marburg, Ebola Hepatitis AHepatitis A

47 Lassa Fever- Rodents Mastomys rat, West Africa Mastomys rat, West Africa Most common directly transmissible VHF of international travelers. Most common directly transmissible VHF of international travelers. Acquire disease by Acquire disease by Inhaling urine, feces of ratInhaling urine, feces of rat Open skin contact with urine/ fecesOpen skin contact with urine/ feces Eating the rodentEating the rodent Incubation: 1-3 weeks Incubation: 1-3 weeks Acute viral illness, 80% asymptomatic, 5000 deaths/ yr Acute viral illness, 80% asymptomatic, 5000 deaths/ yr MMWR: October 1, 2004 / 53(38); MMWR: October 1, 2004 / 53(38);

48 Lassa Fever Gradual onset: H/A, fever, malaise Gradual onset: H/A, fever, malaise GI and Respiratory symptoms GI and Respiratory symptoms Deafness: most common complication (1/3) Deafness: most common complication (1/3) Severe multisystem disease Severe multisystem disease Dx with ELISA: IgM and IgG antibodies Dx with ELISA: IgM and IgG antibodies Person to person spread (body fluids aerosolized) Person to person spread (body fluids aerosolized)

49 Transportation By land By land By boat By boat By air By air

50 3. Exposure History Types Food and Water Food and Water Mosquitoes, ticks, sand flies, and other bugs Mosquitoes, ticks, sand flies, and other bugs Animals Animals New Sexual Partners New Sexual Partners Freshwater Freshwater

51 Exposure: Food and water Hepatitis A Hepatitis A Toxoplasmosis Toxoplasmosis Trichinella Trichinella Enteric fever (typhoid, paratyphoid) Enteric fever (typhoid, paratyphoid) Bacterial gastroenteritis Bacterial gastroenteritis Amoebiasis Amoebiasis

52 Water: Enteric Fever Caused by Salmonella typhi or S. paratyphi Caused by Salmonella typhi or S. paratyphi High fever with relative bradycardia High fever with relative bradycardia Normal WBC count Normal WBC count Blood culture: + 80% Blood culture: + 80% Bone marrow aspirate: + 90% Bone marrow aspirate: + 90% Serology Serology Vaccine is only 50% to 70% efficacious Vaccine is only 50% to 70% efficacious

53 Enteric fever 16 million cases/ worldwide/year 16 million cases/ worldwide/year 200 to 400 positive labs in the US 200 to 400 positive labs in the US 75% in VFRs75% in VFRs 6 top countries 6 top countries INDIA, Pakistan, BangladeshINDIA, Pakistan, Bangladesh MexicoMexico PhilippinesPhilippines HaitiHaiti

54 Meat: Trichinella spiralis Worldwide Worldwide Raw/ undercooked meat Raw/ undercooked meat Pork: Laotian refugeesPork: Laotian refugees Bear/ walrus: Alaskan NativesBear/ walrus: Alaskan Natives MMWR July 16, 2004/ 53(27); MMWR July 16, 2004/ 53(27); Path of infection Path of infection Offspring migrate from small intestine through internal organs end up in striated muscleOffspring migrate from small intestine through internal organs end up in striated muscle Larvae curl up as coils in cystsLarvae curl up as coils in cysts

55 Trichinella spiralis GI symptoms GI symptoms w/i 24 hours: N,V,D, constipation, painw/i 24 hours: N,V,D, constipation, pain Systemic phase Systemic phase High fever, malaise, muscle pain week laterHigh fever, malaise, muscle pain week later EosinophiliaEosinophilia

56 Food and Water: Amoebiasis E. histolytica cysts in water or food E. histolytica cysts in water or food Can be transmitted sexually (MSM) Can be transmitted sexually (MSM) Long latent period: days to years Long latent period: days to years Amoebic liver abscess: ultrasound Amoebic liver abscess: ultrasound Serology to E. histolytica antigens Serology to E. histolytica antigens Dysentery form: Dysentery form: asymptomatic to fulminant necrotizing colitis (immunocompromised)asymptomatic to fulminant necrotizing colitis (immunocompromised) Frequent bloody stools,+/- feverFrequent bloody stools,+/- fever

57 Exposure: Consumption of unpasteurized dairy products Brucella (dogs, goats, cattle, horses)Brucella (dogs, goats, cattle, horses) Enteric feverEnteric fever Salmonella gastroenteritisSalmonella gastroenteritis Tuberculosis (bovis)Tuberculosis (bovis)

58 Dairy: Brucella species Recurrent, prolonged episodes of fever Recurrent, prolonged episodes of fever Worse at nightWorse at night Associated with sweatingAssociated with sweating May have focal area of pain (fever + “cannot walk” = Brucellosis in 3 rd world) May have focal area of pain (fever + “cannot walk” = Brucellosis in 3 rd world) May present with neuropsychiatric symptoms May present with neuropsychiatric symptoms Infection from ingesting dairy products (soft cheeses) not meat of animals Infection from ingesting dairy products (soft cheeses) not meat of animals R/O TB R/O TB

59 Exposure: arthropods Mosquitoes Mosquitoes MalariaMalaria DengueDengue Yellow feverYellow fever JEVJEV West Nile VirusWest Nile Virus Rift Valley Fever: sub- Saharan AfricaRift Valley Fever: sub- Saharan Africa ChikungunyaChikungunya OthersOthers

60 Dengue Most widespread arbovirus Most widespread arbovirus Daytime biting mosquito Daytime biting mosquito 4 serotypes 4 serotypes No cross serotype coverageNo cross serotype coverage Prior dengue fever with one serotype predisposes to the risk of a more serious hemorrhagic disease with future exposurePrior dengue fever with one serotype predisposes to the risk of a more serious hemorrhagic disease with future exposure

61 Dengue: Clinical Symptoms Incubation period: 3 to 8 days Incubation period: 3 to 8 days Acute onset high fever, lasting 5 days Acute onset high fever, lasting 5 days SEVERE myalgias: “break bone fever” SEVERE myalgias: “break bone fever” Retro-orbital H/A, cervical adenopathy Retro-orbital H/A, cervical adenopathy Rash: MP to hemorrhagic, may mimic Rubeolla Rash: MP to hemorrhagic, may mimic Rubeolla

62 Dengue Fever Distribution

63 Mosquitoes: Yellow Fever High fever, headache, malaise, back ache High fever, headache, malaise, back ache 3-6 days following mosquito bite 3-6 days following mosquito bite Shock, liver/ renal failure Shock, liver/ renal failure AFRICA and South America AFRICA and South America 50% mortality 50% mortality

64 Yellow Fever Distribution

65 Mosquitoes: Japanese Encephalitis Asia: majority subclinical Asia: majority subclinical Mild infections: fever with headache. Mild infections: fever with headache. More severe infection: sudden onset headache, high fever, neck stiffness, stupor, coma, occasional convulsions and spastic paralysis. More severe infection: sudden onset headache, high fever, neck stiffness, stupor, coma, occasional convulsions and spastic paralysis. Vaccination recommendations are seasonal Vaccination recommendations are seasonal

66 JE World Distribution Source: Tsai TR, Chang GW, Yu YX. Japanese encephalitis vaccines. In Plotkin SA and Orenstein WA, eds., Vaccines - 3rd edition, WB Saunders, Inc., Philadelphia, PA, 1999;

67 Malaria Fever = Malaria Majority of cases Majority of cases P falciparum P. vivax VFRs: immunity wanes Risks Risks AFRICA India and SE Asia Americas Anopheles mosquito: courtesy of Chris Sanford MD

68 Exposure: Ticks Rocky Mountain spotted feverRocky Mountain spotted fever Crimean-Congo hemorrhagic feverCrimean-Congo hemorrhagic fever Relapsing fever (Borrelia sp.)Relapsing fever (Borrelia sp.) Lyme diseaseLyme disease TularemiaTularemia BabesiosisBabesiosis cbr/L1C-m2.html

69 Ticks: Relapsing fever Spirochete: Borrelia recurrentis Spirochete: Borrelia recurrentis Transmitted by tick or louse Transmitted by tick or louse Endemic form Endemic form Worldwide, mountainous areasWorldwide, mountainous areas Tick is vector, animal reservoir is a rodentTick is vector, animal reservoir is a rodent Epidemic form Epidemic form Secondary to war, povertySecondary to war, poverty No animal reservoir, louse is vectorNo animal reservoir, louse is vector

70 Ticks: Babesiosis (Babesia species) Hemoprotozoan parasite like plasmodium Hemoprotozoan parasite like plasmodium Deer tick Ixodes damini and White- footed mouse: Peromyscus leucopus are the hosts Deer tick Ixodes damini and White- footed mouse: Peromyscus leucopus are the hosts NE United States, Europe, Japan NE United States, Europe, Japan Fever, chills, sweating, myalgias, HSM, hemolytic anemia. Fever, chills, sweating, myalgias, HSM, hemolytic anemia. Thick and thin smears/ indirect fluorescent Ab (IFA) Thick and thin smears/ indirect fluorescent Ab (IFA)

71 Exposure: sand flies LeishmaniasisLeishmaniasis Visceral: fever, weight loss, HSM, anemia Visceral: fever, weight loss, HSM, anemia Develops months to years after exposure Develops months to years after exposure Most common form: cutaneous Most common form: cutaneous Bartonellosis (Oroya fever)Bartonellosis (Oroya fever) W. South America (Peru) W. South America (Peru) Fever, H/A, anemia, migratory joint and muscle pain Fever, H/A, anemia, migratory joint and muscle pain Chronic form: painful dermal nodules Chronic form: painful dermal nodules oom/NasaNews/2002/ ht ml AARP.org

72 Exposure: Other bugs Tsetse flies Tsetse flies African trypanosomiasis (Af. sleeping dz)African trypanosomiasis (Af. sleeping dz) Reduviid bugs Reduviid bugs American trypanosomiasis (Chagas’ disease)American trypanosomiasis (Chagas’ disease) Chiggers Chiggers Scrub typhusScrub typhus

73 Exposure Deer flies Deer flies Loa loa: eye wormLoa loa: eye worm Black flies Black flies Onchocerciasis (river blindness)Onchocerciasis (river blindness) ~parasite/loa.html

74 Exposure Tsetse flies: African trypanosomiasis (African sleeping disease) Tsetse flies: African trypanosomiasis (African sleeping disease) T.b. gambiense (west) T.b. gambiense (west) Fever, H/A, joint painFever, H/A, joint pain CNS laterCNS later T.b. rhodesiense (east) T.b. rhodesiense (east) Fever with rapid systemic symptomsFever with rapid systemic symptoms HSMHSM Anemia, jaundiceAnemia, jaundice

75 Bugs: Chagas’ Disease American trypanosomiasis American trypanosomiasis Romana’s sign Romana’s sign Reduviid bugs Reduviid bugs Live in cracks in mud walls, flooring Live in cracks in mud walls, flooring Fever 1-2 weeks Fever 1-2 weeks Lymph, HSM Lymph, HSM Chronic years Chronic years

76 Chiggers : Scrub typhus SE Asia and SW Pacific SE Asia and SW Pacific Bite: ulcerates Bite: ulcerates 6-18 days post bite 6-18 days post bite Sudden T> 104, severe H/A, myalgia, relative bradycardia Sudden T> 104, severe H/A, myalgia, relative bradycardia End of first week: Rash, HSM, general adenopathy End of first week: Rash, HSM, general adenopathy

77 Exposure Animals Animals RabiesRabies TularemiaTularemia Q feverQ fever AnthraxAnthrax PlaguePlague Viral hemorrhagic fevers (Lassa, etc.)Viral hemorrhagic fevers (Lassa, etc.)

78 Ticks/ Animals: Tularemia Tick bite: ulceroglandular form Tick bite: ulceroglandular form Broken skin contact with carcass Broken skin contact with carcass Inhalation Inhalation Ingestion of meat, contaminated water Ingestion of meat, contaminated water NA, Europe, Asia NA, Europe, Asia “Atypical pneumonia” “Atypical pneumonia” Axillary nodes, fever, H/A, SOB, joint pain Axillary nodes, fever, H/A, SOB, joint pain Category A bioterrorism Category A bioterrorism

79 Rabies rule: If it has fur and teeth do not touch it.

80 Exposure: New sexual partners HIV HIV Hepatitis B Hepatitis B Other STDS: herpes, gonorrhea, syphilis, HPV, lymphogranularum inguinal Other STDS: herpes, gonorrhea, syphilis, HPV, lymphogranularum inguinal

81 Swimming Exposure Fresh water Schistosomiasis Schistosomiasis Leptospirosis Leptospirosis Hepatitis A Hepatitis A

82 Exposure: Freshwater

83 Schistosomiasis Parasite penetrates human skin Parasite penetrates human skin Migrate to blood stream Migrate to blood stream Katayama fever: S. mansoni Katayama fever: S. mansoni fever, headache, cough, transitory hives, lymphadenopathy, HSM, eosinophiliafever, headache, cough, transitory hives, lymphadenopathy, HSM, eosinophilia Mid East, Africa, eastern S. America and CarribeanMid East, Africa, eastern S. America and Carribean Transverse myelitisTransverse myelitis

84 Fresh water: Schistosomiasis S. japonium: Philippines and China S. japonium: Philippines and China seizuresseizures S. mekongi: Cambodia, Laos S. mekongi: Cambodia, Laos Portal hypertensionPortal hypertension S. haematobium: Mid East and Africa S. haematobium: Mid East and Africa HematuriaHematuria transverse myelitistransverse myelitis

85 Fresh Water: Leptospirosis Most common zoonosis worldwide Most common zoonosis worldwide Spirochyte that lives in kidney Spirochyte that lives in kidney Agricultural: Rice/sugarcane workers/farmers Agricultural: Rice/sugarcane workers/farmers Recreational: adventure traveler, fisherman, Borneo 2000 Recreational: adventure traveler, fisherman, Borneo 2000 Rats/mice, mongooses/dogs, pigs/cattle Rats/mice, mongooses/dogs, pigs/cattle Animal urine contaminates water and soil Animal urine contaminates water and soil

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87 Leptospirosis Courtesy of Elaine Jong MD

88 Fresh Water: Leptospirosis Incubation 7 to 14 days Incubation 7 to 14 days Abrupt fever> 39, chills Abrupt fever> 39, chills Frontal H/A (“worst H/A of life”) Frontal H/A (“worst H/A of life”) Muscle pains Muscle pains GI GI Pulm: cough, hemoptysis, CP Pulm: cough, hemoptysis, CP Rash Rash Later: Aseptic meningitis, iritis/ uveitis, possible psychiatric symptoms Later: Aseptic meningitis, iritis/ uveitis, possible psychiatric symptoms

89 4. Incubation period: <21 days: Malaria Malaria Dengue Dengue Yellow fever Yellow fever Japanese encephalitis Japanese encephalitis Meningococcemia Meningococcemia Leptospirosis Leptospirosis Typhoid fever Typhoid fever East African trypanosomiasis East African trypanosomiasis

90 4. Incubation period: >21 days Malaria (esp. after ineffective prophylaxis) Malaria (esp. after ineffective prophylaxis) Acute HIV Acute HIV Acute systemic Schistosomiasis (Katayama fever) Acute systemic Schistosomiasis (Katayama fever) Viral hepatitis (A, B, C, D, E) Viral hepatitis (A, B, C, D, E) Tuberculosis Tuberculosis Leishmaniasis Leishmaniasis West African trypanosomiasis West African trypanosomiasis

91 5. Pre-travel preparations ImmunizationsImmunizations Assess malaria riskAssess malaria risk use of personal protection measures (DEET, permethrin, bed net)use of personal protection measures (DEET, permethrin, bed net) was patient bitten by insects?was patient bitten by insects? compliance re malaria prophylaxiscompliance re malaria prophylaxis appropriate malaria prophylaxisappropriate malaria prophylaxis

92 Work up Laboratory tests Everyone with post travel fever (>101): Everyone with post travel fever (>101): CBC with diff: eosinophilia is abnormalCBC with diff: eosinophilia is abnormal If potential for malaria If potential for malaria thick and thin blood smear(s)thick and thin blood smear(s) Consider saving a tube of serum (acute-phase sample) for later serology Consider saving a tube of serum (acute-phase sample) for later serology

93 Laboratory tests Consider Consider LFTs: Mild elevations (2-3 x upper range of normal) --non-specific. Marked elevation suggests acute hepatitis.LFTs: Mild elevations (2-3 x upper range of normal) --non-specific. Marked elevation suggests acute hepatitis. Stool studiesStool studies CXR if symptomaticCXR if symptomatic PPDPPD

94 Laboratory tests Consider Consider blood culture (typhoid fever, sepsis)blood culture (typhoid fever, sepsis) serology (if initial studies are negative and fever and/or illness persists)--rickettsial diseases, fungal diseases, brucella, Lyme disease, arboviruses, leptospirosis, filariasis, schistosomiasis.serology (if initial studies are negative and fever and/or illness persists)--rickettsial diseases, fungal diseases, brucella, Lyme disease, arboviruses, leptospirosis, filariasis, schistosomiasis. If abdominal pain If abdominal pain low threshold for ultrasound or CT of abdomen (amoebic liver abscess)low threshold for ultrasound or CT of abdomen (amoebic liver abscess)

95 Case 1: 23 y.o. Nursing Student Returns from 3 week stay with relatives in rural India High feverHigh fever Constipation early, now N,V,DConstipation early, now N,V,D HR 60, BP 90/60.HR 60, BP 90/60. Had hepatitis A vaccine prior to tripHad hepatitis A vaccine prior to trip Appears very illAppears very ill Denies mosquito bites and took malaria prophylaxis dailyDenies mosquito bites and took malaria prophylaxis daily

96 Case y.o. anthropology TA returns from 10 day dig in Bolivia 27 y.o. anthropology TA returns from 10 day dig in Bolivia Multiple insect bites Multiple insect bites Rural areas, stayed in local housing Rural areas, stayed in local housing Sudden onset fever, H/A, myalgias Sudden onset fever, H/A, myalgias Anemia and thrombocytopenia Anemia and thrombocytopenia Bites are not infected, no purpura, no cough Bites are not infected, no purpura, no cough

97 Possible Diagnoses MALARIA MALARIA Dengue Dengue American Trypanosomiasis American Trypanosomiasis Bartonellosis Bartonellosis Why not Scrub typhus or JEV? Why not Scrub typhus or JEV?

98 Case #3 21 y/o female student returns from 3 mo July through September trip to Botswana in Okayonga delta 21 y/o female student returns from 3 mo July through September trip to Botswana in Okayonga delta Did some hiking in rural areas, had to cross small stream early in her trip Did some hiking in rural areas, had to cross small stream early in her trip Has fever, headache, myalgias, sore throat, joint aches, fatigue and swollen cervical nodes Has fever, headache, myalgias, sore throat, joint aches, fatigue and swollen cervical nodes

99 Case #3 VS Temp 100.7, RR 20, Pulse 80, BP 100/72 VS Temp 100.7, RR 20, Pulse 80, BP 100/72 Appeared slightly ill Appeared slightly ill Skin warm, dry Skin warm, dry No rash or obvious bites No rash or obvious bites +cervical nodes +cervical nodes Injected pharynx Injected pharynx Heart, lungs, abdomen, joints normal Heart, lungs, abdomen, joints normal Diagnosis? Diagnosis?

100 Case #3 Strep Pharyngitis, Mono Strep Pharyngitis, Mono Influenza from Southern hemisphere Influenza from Southern hemisphere Malaria: non-malaria season Malaria: non-malaria season Dengue: normal CBC Dengue: normal CBC Schistosmiasis: no eosinophils Schistosmiasis: no eosinophils Leptospirosis: 7-10 days incubation Leptospirosis: 7-10 days incubation Other history Other history

101 Case y.o. medical student returned from SE Asia Usually healthy woman with fever, arthralgias; did have diarrhea Usually healthy woman with fever, arthralgias; did have diarrhea In India, Laos, Thailand, Burma (Feb-Mar)In India, Laos, Thailand, Burma (Feb-Mar) intermittent use of DEET and bed netintermittent use of DEET and bed net no fresh water or animal exposureno fresh water or animal exposure Low budget accommodationsLow budget accommodations sexually active. BC: condoms. LMP: 5 weeks prior to first visit with post-travel physician.sexually active. BC: condoms. LMP: 5 weeks prior to first visit with post-travel physician. medications: doxycycline for acne (used this for malaria prophylaxis too)medications: doxycycline for acne (used this for malaria prophylaxis too)

102 Work up Labs: multiple malaria smears - negative Labs: multiple malaria smears - negative CBC: mild anemia, slight leukopenia, borderline thrombocytopenia CBC: mild anemia, slight leukopenia, borderline thrombocytopenia blood culture: negative blood culture: negative UA: negative UA: negative CXR: normal CXR: normal PPD: 0 mm induration PPD: 0 mm induration Urine pregnancy test: negative. Urine pregnancy test: negative.

103 Diagnostic possibilities Dengue, Chikungunya, JEV Dengue, Chikungunya, JEV Scrub typhus Scrub typhus Reiters’ post dysentery Reiters’ post dysentery RF: negative RF: negative ANA: positive at 1:320 titer. Pattern: diffuse. Anti-ss DNA present. ANA: positive at 1:320 titer. Pattern: diffuse. Anti-ss DNA present.

104 Case study: post-travel fever Doxycycline stopped followed by all symptoms clearing within a few weeks. Doxycycline stopped followed by all symptoms clearing within a few weeks. Final diagnosis: drug-induced lupus. Final diagnosis: drug-induced lupus.

105 Post travel Questions Where did you go? Where did you go? When were you there and how long did you stay? Where did you stay? When were you there and how long did you stay? Where did you stay? What did you do or not do? What did you do or not do? What did you drink? What did you drink? Where did you swim? Where did you swim? When did you become ill? When did you become ill? What meds did you take? What meds did you take? What vaccines have you had? What vaccines have you had?

106 Many Thanks Jean Haulman MD

107 Bibliography DuPont HL, Steffen R (eds.): Textbook of Travel Medicine and Health, 2nd Ed. B.C. Decker, DuPont HL, Steffen R (eds.): Textbook of Travel Medicine and Health, 2nd Ed. B.C. Decker, Keystone JS, Kozarsky PE, Freedman DO, et al, eds: Travel Medicine. Mosby, Keystone JS, Kozarsky PE, Freedman DO, et al, eds: Travel Medicine. Mosby, McLellan, SLF: Evaluation of fever in the returned traveler. In Sanford C (guest ed.) Primary Care Clinics: Travel medicine. Saunders/Elsevier Dec McLellan, SLF: Evaluation of fever in the returned traveler. In Sanford C (guest ed.) Primary Care Clinics: Travel medicine. Saunders/Elsevier Dec International Travel Health Guide & National Travel Health Network and Centre International Travel Health Guide & National Travel Health Network and Centre Sanford C. (guest editor): Primary Care Clinics: Travel Medicine. Sauners/Elsevier, December Sanford C. (guest editor): Primary Care Clinics: Travel Medicine. Sauners/Elsevier, December 2002.

108

109 Malaria

110 Malaria All fever is malaria until proven otherwise All fever is malaria until proven otherwise Cannot be diagnosed clinically Cannot be diagnosed clinically Suspect malaria based on history, epidemiology, and exam Suspect malaria based on history, epidemiology, and exam Diagnosis is established by laboratory exam (thick and thin blood smears.) Diagnosis is established by laboratory exam (thick and thin blood smears.)

111 Fever Stats (>100.4 to >101.5) All 3 rd world fevers are due to MALARIA until proven otherwise All 3 rd world fevers are due to MALARIA until proven otherwise The approach to the febrile patient should consider travel and exposure history, pre-travel vaccinations, and malaria prophylaxis. The approach to the febrile patient should consider travel and exposure history, pre-travel vaccinations, and malaria prophylaxis.

112 Serious Febrile Illness related to EXPOSURE Food and water Food and water hepatitis A*, toxoplasmosis,trichinella, enteric fever (typhoid, paratyphoid) *, bacterial gastroenteritis, amoebiasishepatitis A*, toxoplasmosis,trichinella, enteric fever (typhoid, paratyphoid) *, bacterial gastroenteritis, amoebiasis Unpasteurized Dairy Unpasteurized Dairy Brucella (dogs, goats, cattle, horses),enteric fever *, Salmonella gastroenteritis, tuberculosis (bovis) Brucella (dogs, goats, cattle, horses),enteric fever *, Salmonella gastroenteritis, tuberculosis (bovis) Mosquitoes Mosquitoes Malaria, dengue, filariasis, loa loa, yellow fever *, Japanese encephalitis*, ChikungunyaMalaria, dengue, filariasis, loa loa, yellow fever *, Japanese encephalitis*, Chikungunya Ticks Ticks tick typhus, Rocky Mountain spotted fever, Crimean-Congo hemorrhagic fever, lyme disease, relapsing fever (Borrelia spp.), tularemia, babesiosistick typhus, Rocky Mountain spotted fever, Crimean-Congo hemorrhagic fever, lyme disease, relapsing fever (Borrelia spp.), tularemia, babesiosis Sand flies Sand flies Leishmaniasis, sandfly fever, bartonellosis (Oroya fever) Black flies Black flies onchocerciasis (river blindness) Tsetse flies Tsetse flies African trypanosomiasis (Af. sleeping dz) Reduvid bugs Reduvid bugs American trypanosomiasis (Chagas’ disease) Chiggers Chiggers scrub typhus ***There is no safe drinking water in developing countries***

113 Serious Febrile Illness related to EXPOSURE Caves Caves rabies (bat bite, or bat guano inhalation) *, histoplasmosisrabies (bat bite, or bat guano inhalation) *, histoplasmosis Desert areas Desert areas CoccidiomycosisCoccidiomycosis Animals Animals Brucellosis, rabies *, tularemia, Q fever, anthrax, plague, viral hemorrhagic fevers (Lassa, etc.)Brucellosis, rabies *, tularemia, Q fever, anthrax, plague, viral hemorrhagic fevers (Lassa, etc.) Fresh water Fresh water schistosomiasis,leptospirosis, hepatitis A *schistosomiasis,leptospirosis, hepatitis A * Crowded living conditions, group travel Crowded living conditions, group travel meningococcal disease *, influenza *, tuberculosis, Lassa, Marburg, ebola, hepatitis A * New intimacy New intimacy HIV, hepatitis B *, other STDS: herpes, gonorrhea, syphilis, HPV *, etc. Loss of Common Sense Loss of Common Sense ***Only 8 diseases have vaccines to prevent disease***


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