Approach to Febrile Traveller

Question 1

There are 6 parts to the general approach to a febrile traveller

Answer 1

Routine hx
Focused travel hx
Physical findings
DDx
Lab confirmation
Mgmt decisions

Question 2

What are the components of a routine hx?

Answer 2

Fever pattern
Full review of systems
PMHx
Meds

Question 3

Consideration when looking at fever pattern

Answer 3

Consider non-infectious fever causes
Thromboembolism
Malignancy
Autoimmune disease

Question 4

What should be included when looking travel history?

Answer 4

Itinerary
Timeline
Purpose of travel
Prophylactic measures

Question 5

What should be assessed in the travel itinerary?

Answer 5

Areas travelled
Places of transit
Mode of travel

Question 6

What should be assessed in the travel timeline?

Answer 6

Time spent in each area
This helps with Ddx
Longer trip = ↑ likelihood of travel related illness

Question 7

What period of travel hx should be looked at?

Answer 7

6mo minimum; up to a year

Question 8

What purpose of travel has the highest risk of acquiring travel related infections?

Answer 8

• Visiting friends and relatives r/t higher likelihood of street food exposure

Question 9

What are prophylactic measures that can be taken pre-travel to reduce the the risk of travel related illness?

Answer 9

• Immunization (Routine & Travel related)
• Chemo-prophylaxis

Question 10

What are prophylactic measures that can be taken during travel to reduce the the risk of travel related illness?

Answer 10

Appropriate clothing
Insecticides
Tick bite vigilance
Bed nets
Bottled drinking water
Avoid uncooked food
Handwashing

Question 11

During the physical exam, what should be assessed?

Answer 11

Head to toe assessment
Be sure to look at mucous membranes, skin, and lymph nodes

Question 12

Rose spots are associated with what disease?

Answer 12

Typhoid fever

Question 13

Petechiae is associated with what travel related disease?

Answer 13

Dengue fever

Question 14

Eschar is associated with what travel related disease?

Answer 14

Scrub typhus

Question 15

This skin condition is associated with meningicoccus disease

Answer 15

Ecchymosis

Question 16

The appearance of this in the mucous membrane is diagnostic of measles

Answer 16

Koplic spots

Question 17

This is the top diagnosed disease in febrile travellers

Answer 17

Malaria - up to 30%

Question 18

There is an exo-erythrocytic cycle and erythrocytic cycle to the plasmodium life cycle in the human body. What are the symptoms associated with the exo-erythrocytic cycle?

Answer 18

Elevated transaminases

Question 19

There is an exo-erythrocytic cycle and erythrocytic cycle to the plasmodium life cycle in the human body. What are the symptoms associated with the erythrocytic cycle?

Answer 19

Hemolysis
Anemia
Splenomegaly
Thrombocytopenia
Cyclic fevers
Rigors
Headache
Vasular and endothelial dmg

Question 20

Cyclic fever is associated with malaria. What causes this?

Answer 20

Release of pro inflammatory cytokines r/t rupture of RBC with schizont inside it

Question 21

Diagnosis of malaria requires what type of diagnostic test to determine the presence of malaria and the type?

Answer 21

Thick and thin smear
Thick - is parasite present
Thin - what type is present

Question 22

This diagnostic test is rapid and good for detection of p. Falciparum

Answer 22

Antigen test

Question 23

This diagnostic test is able to detect very low lvl of plasmodium in the blood

Answer 23

PCR

Question 24

What does the choice of oral anti-malarial tx depend on?

Answer 24

Malaria sp.
Region of travel and local resistance pattern

Question 25

What pathogens can cause traveller’s diarrhea? (3)

Answer 25

Bacteria Viruses Parasites

Question 26

What bacteria can cause traveller’s diarrhea? (6)

Answer 26

ETEC (most common) Campylobacter jejune Salmonella sp. Shigella sp. C. Diff Vibrio sp.

Question 27

What viruses can cause traveller’s diarrhea? (3)

Answer 27

Rotavirus Norovirus Adenovirus

Question 28

What parasites can cause traveller’s diarrhea? (5)

Answer 28

Giardia lamblia Cyclospora cayetensis Crytospordium parvum Cystisospora belli Entamoeba histolytics

Question 29

What are prophylaxis prevention options for traveller’s diarrhea?

Answer 29

ETEC vaccine — Dukoral Bismuth subsalicylate (pepto bismol) Abx prophylaxis isn’t recommended

Question 30

What is the treatment for mild traveller’s diarrhea?

Answer 30

Loperamide Pepto Hydration and supportive care

Question 31

What is the treatment for moderate traveller’s diarrhea?

Answer 31

Loperamide May or may not use abx Abx more effective with loperamide

Question 32

What is the treatment for severe traveller’s diarrhea?

Answer 32

Abx Supportive care

Question 33

This pathogen causes typhoid fever

Answer 33

Salmonella enterica Serotype typhi or paratyphi

Question 34

What organs are impacted by typhoid fever?

Answer 34

GI tract and liver Bacteremia —> bone marrow, gallbladder, sleeper, peyer’s patches in terminal ileum

Question 35

What are the clinical features of typhoid fever?

Answer 35

Fever Fatigue Diarrhea/constipation Rose spots (blanching pink/red rash) Relative bradycardia Abdominal tenderness Hepato-splenomegaly

Question 36

How is typhoid fever diagnosed?

Answer 36

Blood cultures Bone marrow cultures Stool culture Widal test (poor specificity) General labs — CBC and liver workup

Question 37

What is the management of typhoid fever?

Answer 37

Depends on region of travel due to variation in resistance based on region

Question 38

This travel related-illness is characterized by “breakbone fever” (fever, bone, and joint pain), and petechiae rash.

Answer 38

Dengue fever

Question 39

What is the basic workup for a traveller returning with a fever?

Answer 39

CBC Liver enzymes Creatinine Electrolytes Blood culture Urinalysis