1. Fever in the returning traveller Part II
Dr Viviana Elliott
Consultant Acute Medicine

2. 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

3. Malaria
Should be thought in febrile illness in travellers returning to Europe from tropic
Sub - Saharan
Africa

4. Malaria

5. Early diagnosis and assessment of severity is vital to avoid deaths
Symptoms 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

6. 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

7. La Laboratory diagnostic approach Diagnostic Approach
FBC
↑WBC with neutrophils
↓ WBC with neutrophils
↓ WBC with lymphocytes
Pneumonia
UTI
Leptospirosis
Brucella
Typhoid
Other Salmonella
Viral
Rickettsial
Eosinophils: helminth, drugs. Unlikely bacterial
LFTs
Very High
High bili + Mod trans + Renal disfunction
Viral hepatitis
Yellow fever
Toxin
Leptospirosis

9. Falciparum Malaria or mixed infection

10. Admit all cases and assess severity

11. Complicated Malaria

12. Treatment

13. Enteric Fever (Typhoid and Paratyphoid))
Commonest serious tropical disease from Asia
Distribution: worldwide in developing countries
Asia and south east Asia
>100 cases per person per year
77% in person visiting friends and family
Most cases occur 7 – 18 days after exposure
range 3-60 days

14. Clinical Presentation of Enteric Fever
Fever is almost invariable
Relative bradycardia only first week

15. Clinical presentation of Enteric Fever
Constipation more common than diarrhoea
initial loose stools fairly common
Maybe evanescent rash: “Rose spots”

16. Investigations First Week:
Bloods: low WBC, platelets and mildly raised LFTs
BCM positive %
Second week
Urine culture %
Stool culture %
Bone marrow higher sensitivity than BCM
Newer rapid serology IgM against specific S Typhi
Widal test lacks sensitivity and specificity Not recommended

17. Complications Incidence: 10-15% illness >2 weeks GI Bleed
Intestinal perforation
Typhoid encephalopathy
Vaccination provides incomplete protection

18. 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

19. Rickettsia: Common infection in travellers to games parks in southern Africa

20. Ricketssias Rickettsia Africae Conorii Typhi Orientia Tsusugamuyi
African tick
bite 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 Asia
Western pacific
Infrequently report by travellers
Complications
Fatal 32%
Fatal 2%
If untreated:
Pneumonitis, CID,ARF and Meningoencephalitis

21. 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)

22. R Conorii: single
R Africae: multiple
R Typhi

23. 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

24. 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 million per year
Transmission: Aedes aegypty

26. 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

27. Dengue
2 days later

28. Dengue Haemorrhaic Fever (DHF) Plasma leak
Haemorrhagic
Manifestations
Platelets < 100
Dengue Haemorrhaic Fever (DHF)
10-20% Mortality
Plasma leak
> 20% in pack cells volumen
↓Protein
Clinical effusions

29. Dengue Shock Syndrome
Mortality rate up to 40%
Narrowing pulse pressure <20 mmHg or BP < systolic of < 90 mmHg

30. 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.

31. 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

34. 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)

35. 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

36. 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

38. Leptospirosis clinical presentation
Incubation : 7 – 12 days (range 2-30 days)
Initial phase: “flu like symptoms” lasting days
Immune phase: “Weil’s disease”
1-3 days later
fever, myalgia (calves)
haepatorrenal syndrome
haemorrhages
Conjunctiva suffusions suggestive

39. 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

40. 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

41. 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)

42. 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

43. Investigations FBC neutrophil leucocytosis > 10 X 10 6 L
LFT dearranged ↑↑ Alk Pho
CRP/ESR raised
Indirect haemagglutination >90% sensitivity
Stools negative
CxR Raised hemi-diaphragm
USS DD piogenic abscess (percutanous aspiration) R/O Hydatidic disease first!

44. Amoebic Liver abscess

45. 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

46. 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.

47. 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

48. Other complications Epididymo-orchitis Septic abortions
Neurological: meningitis encephalitis brain abcess
Endocarditis: Aortic valve and requires early surgery

49. 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 %

50. 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

51. 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

52. 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

54. 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

55. 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

56. 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)