1. Fever in a returned traveller
Ouli Xie
Intern

2. Fever in a returned traveller
30 year old man presents with fever 38.5C associated with abdominal pain
Returned 2 months ago from a 3 week trip to India
Multiple exposures and no travel prophylaxis
Associated with 2 days of loose bowels but now BNO for 2 days
Some nausea but no vomiting
PHx: Nil
Meds: Nil

3. Examination Haemodynamically stable, T 38.5C
Diaphoretic, unwell looking
Fluid depleted
Dual heart sounds, no murmur
Chest clear to auscultation
Tender RIF on palpation, but abdomen soft

4. DDx? Malaria Bacterial enteritis Inflammatory bowel disease
Appendicitis!

5. An approach History Travel/exposure history Examination
Common causes of fever
Causes not to miss
Investigations
Treatment

6. History Time course is essential
Including progression of illness
Incubation period can help distinguish illnesses
Dengue unlikely after 2 weeks
Associated features
Rash, headache, GI symptoms, myalgia/arthralgia etc.

7. Exposure history T O A D S
– travel – specific places and dates rural/urban – occupation – activities – detailed list of activities animals, fresh water, food etc. – drugs – including IVDU – sex

8. Causes Travel specific More prevalent in area of travel
Malaria
Dengue
Bacterial enteritis
More prevalent in area of travel
Influenza
Respiratory illnesses
General causes of fever
Appendicitis etc.

9. The big 3
Malaria
Typhoid
Dengue

10. Malaria Caused by mosquito-borne protozoan
Plasmodium falciparum
Plasmodium ovale
Plasmodium vivax
Plasmodium malariae
Plasmodium knowlesi
Carried by dawn/dusk biting Anopheles mosquito
Multiple stages in life cycle

11. Malaria life cycle

12. Characteristic features
Falciparum malaria can be fulminant and cause death
Ovale and vivax have dormant liver stages and may reactivate
Malariae may have low levels of parasetaemia and recrudesce weeks after infection
Characteristically described as cyclical fevers

13. Falciparum malaria The most common cause of symptomatic malaria
Risk of complicated malaria
Systemic symptoms or high level of parasetaemia >5%
Incubation days
Associated with high levels of chloroquine resistance

14. Complicated malaria Systemic symptoms or high parasetaemia
Altered conscious state +/- seizures
ARDS
Circulatory collapse
Metabolic acidosis
Renal failure or haemaglobinuria
Haptic failure
Coagulopathy +/- DIC
Severe anaemia
Hypoglycaemia

15. Clinical features Hx Examination High cyclical fevers
May have non-specific associated features including:
Headache, cough, nausea/vomiting, diarrhoea, abdo pain, myalgias/arthralgias
Examination
Splenomegaly
Jaundice

16. Diagnosis Thick and thin films Rapid diagnostic tests
Operator dependent
Serial films required
Rapid diagnostic tests
ICT used at RMH (immunochromatographic test)
Used to detect malaria antigens
Can distinguish between Falciparum and non-falciparum malaria
Sensitivity and specificities ~95%

17. Treatment
Artesunate is the preference for treatment of falciparum malaria
3 day course of artemether-lumefantrine
IV form available for severe falciparum malaria
Always given in combination to prevent resistance
Non-faciparum malaria can be treated with chloroquine if sensitive
Note primaquine required for liver stage of vivax and ovale

18. Dengue 4 serotypes Carried by day-biting mosquito Aedes aegypti
Usually not lethal
Risk of dengue haemorrhagic fever
Infection with 1 serotype results in super-antigen response
Circulatory collapse and haemorrhage/coagulopathy

19. Dengue clinical features
History
Fever, arthalgias, myalgias and severe headache (often retro-orbital)
“Breakbone fever”
Maculopapular rash
Examination
Non-specific
May find some lymphadenopathy, rash, hepatomegaly

20. Diagnosis and treatment
Basic bloods
Classically shows a thrombocytopaenia and leukopaenia
Diagnosis
Dengue serology
Dengue PCR/ELISA
Treatment
Supportive

21. Enteric fever Typhoid/paratyphoid fever
Caused Salmonella enterica serotype Typhi or serotype paratyphi
Faecal-oral spread
Typhoid Mary
Can be associated with chronic carriage
Colonisation of biliary system
Incubation 5-21 days

22. Clinical features Hx Exam Classic progression described
Rising fever in first week
Abdo pain in second week with appearance of rash
Septic shock in third week
May describe constipation or diarrhoea
Exam
Characteristic rose spot rash
Abdo pain, hepatosplenomegaly

23. Investigations Basic investigations Diagnosis
May demonstrate a leukocytosis or leukopaenia
Abnormal LFTs even in hepatitic pattern
Diagnosis
Blood culture (+ve in 40-80%)
May also be cultured in stool or urine
Serology minimal value

24. Treatment Supportive treatment Antibiotic therapy
Azithromycin or ceftriaxone
Ciprofloxacin useful if susceptible
Beware resistance against fluoroquinolones in South/South-East Asia

25. Summary Take a careful history
Remember that fever in returned traveler does not have to be a travel related illness!
Remember the big 3 – malaria, dengue and enteric fever
Time course can often be the key

26. References
Uptodate
Yung, Allen P (2005). Infectious diseases : a clinical approach (2nd ed). IP Communications, East Hawthorn, Vic
Kumar P and Clark M (Eds) (2009) Kumar and Clark’s Clinical Medicine (7th edition). Edinburgh: Saunders Elsevier.