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Fever in the returning traveller Flashcards

1
Q

What is the aim of the travel history?

A

To assess an individual’s risk of having acquired a specific infection i.e. to determine specific exposures/contacts depending on the geographical history.

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2
Q

What is important to note in the travel history?

A

The time of onset and duration of symptoms

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3
Q

When do most tropical infections become symptomatic?

A

Within 21 days of exposure

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4
Q

When do the majority of tropical infections present?

A

Within one month of leaving endemic areas

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5
Q

How many travellers report illness?

A

Almost 2/3

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6
Q

How many % of travellers will seek medical attention? How many of these require hospital admission?

A

8%

11%

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7
Q

How many present with fever? How many of these require hospital admission?

A

28%

26%

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8
Q

What are some of the most common causes of fever in the returning traveller?

A

Unspecified febrile illness
Malaria
Acute diarrhoeal illness

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9
Q

Don’t forget… as they are common.

A

non-tropical infections & non-infectious

causes

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10
Q

What to ask in the travel history? (6)

A

Where? - exact location & setting, e.g. rural, urban
When? - exact dates of travel, season e.g rainy
Why? - visiting family vs tourist
What? (exposures) - recreational, occupational (e.g. healthcare), cultural (e.g. burials), dietary, illness
Who? - travel companions, unwell contacts, sexual contacts
Preventative Measures/empiric therapy - vaccination (can affect serology results), malaria prophylaxis, compliance

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11
Q

Sub-Saharan Africa - name some diseases that can cause fever in the returning traveller? (6)

A 
Malaria
Dengue / Chikungunya
Rickettsiae
Enteric Fever (Typhoid)
HIV/seroconversion illness
Viral haemorrhagic fever (Lassa, Ebola, Marburg, Crimean-Congo HF)
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12
Q

What can cause fever in HIV/seroconversion illness patients?

A

OPPORTUNISTIC INFECTION

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13
Q

Epidemiology of VHF.

A

VERY RARE

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14
Q

Briefly discuss Lassa fever.

A

ENDEMIC, present in rodents, 20% of exposed become infected/develop symptoms, rural, not big outbreaks.

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15
Q

Consider VHF if…

A

Fever AND visited endemic area < 21 d

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16
Q

High possibility of VHF if any:

A

• Contact with / care for febrile person (>4h)
• Health care / laboratory / vet work
• Contact with confirmed cases / outbreak /
animals
• Shock, organ failure, haemorrhage

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17
Q

Briefly discuss ebola.

A

EPIDEMIC, 80% exposed develop symptoms

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18
Q

What is CCHF transmitted by?

A

Ticks

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19
Q

Initial management of VHF.

A
  • Malaria film, clotted blood, EDTA blood
  • Isolation / PPE / Infection control
  • Discuss with Infectious Diseases / Micro
  • Virologist, CCDC (Public Health)
  • VHF PCR
  • Keep a list of contacts who may need following up

Guidance: Advisory Committee for Dangerous Pathogens, Management of Hazard Group 4 viral
haemorrhagic fevers and similar human infectious
diseases of high consequence

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20
Q

What infection control precautions if a patient is ambulatory/self-caring/controlled body fluids?

A

Standard plus droplet precautions required:

  • Hand hygiene
  • Gloves
  • Gown
  • Fluid repellent surgical facemask

For aerosol or splash-inducing procedures:

  • FFP3 respirator
  • Eye protection
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21
Q

What infection control precautions if a patient is bruising, bleeding, uncontrolled vomiting or diarrhoea…

A 
Standard plus droplet plus splash plus aerosol:
Double gloves
Fluid repellent disposable gown 
FFP3 respirator
Eye protection
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22
Q

South and Central Asia - name some diseases that can cause fever in the returning traveller? (5)

A 
Dengue
Enteric Fever
Malaria
Chikungunya
Tuberculosis
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23
Q

South East Asia - name some diseases that can cause fever in the returning traveller? (4)

A

Dengue
Enteric Fever
Chikungunya
Malaria

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24
Q

Latin America and Caribbean - name some diseases that can cause fever in the returning traveller? (3)

A

Dengue / Chik / Zika
Enteric Fever
Malaria

Plus fungal infections e.g. brucellosis, coccidioidomycosis, histoplasmosis

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25
What illnesses have short incubation periods (<10 days)?
Bacterial / viral gastroenteritis Dengue, Chik, Zika Resp tract infection, UTI, meningitis, Rickettsia
26
What illnesses have medium incubation periods (10-21 days)?
``` Malaria, Typhoid, Rickettsia, EBV, CMV, HIV, Leptospirosis, VHF, Trypanosomiasis Endemic fungi (histoplasmosis) ```
27
What illnesses have long incubation periods (>21 days)?
``` Malaria, HIV, Hepatitis A-E, TB Acute schistosomiasis, Amoebic liver abscess, Brucellosis, Visceral Leishmaniasis, Trypanosomiasis ```
28
Who is more at risk of getting some infections (malaria, typhoid, tuberculosis, hep A and sexually-transmitted infections incl. HIV) - tourists or people visiting friends and relatives in developing countries? Why?
People visiting friends and relatives in developing countries Less likely to seek pre-travel advice, occupational hazards, less likely to seek advice/take prophylaxis
29
A patient has returned from Sub-Saharan Africa. He has a history of swimming in fresh/brackish water 2-12 weeks ago. On examination, he has "swimmer's itch". On his lab results, he has a raised eosinophil count. What is the diagnosis?
Acute Schistosomiasis
30
A patient has returned from South East Asia. He has a history of swimming/rafting in fresh water less than 4 weeks ago. On examination, he appears jaundiced and has conjunctival suffusion. On lab results, it shows liver/renal impairment. What is the diagnosis?
Leptospirosis
31
A man has recently returned from a game park in Southern Africa, where he was bitten by a tick. He reports a headache. On examination, you notice he has a fever, also eschar (dry dark scab) and a maculopapular rash. What is the diagnosis?
Tick Typhus
32
A man has recently returned from Sub-Saharan Africa where he was bitten by something, which was very painful. On examination, you notice a chancre. What is the diagnosis and what was he bitten by?
Trypanosomiasis | Tsetse fly
33
A man has returned from Africa. He has a necrotic ulcer and oedema. What is the diagnosis?
Anthrax
34
Name some diseases transmitted by animal contact/bites. (4)
Rabies Brucella Q fever VHF
35
What diseases do bats transmit?
Histoplasmosis, rabies and ebola
36
Exposure - unprotected sex. What is this person at risk of? (5)
``` HIV seroconversion Syphilis Viral hepatitis Gonococcaemia STI ```
37
Pre-travel history. What to check?
Find out if the patient had / was up to date with relevant vaccinations for places of travel (but not 100% effective!) Find out if the patient took malarial prophylaxis, which one and if they were compliant and where they obtained it. Ask about any treatment e.g. anti-malarials, antibiotics, any over the counter treatment, AND ANY SIDE EFFECTS
38
What is generally found on examination? (3)
Ill, jaundice, anaemia
39
What are the danger signs? (4)
- Altered mental status, meningism - Respiratory distress - Shock - Liver / renal impairment
40
What other signs are there on examination? (3)
Lymphadenopathy Skin (expose well!): - Rash / eschar / ulcer / vesicles / urticaria Hepato / Splenomegaly
41
What sign do you never get with malaria?
Lymphadenopathy (don’t usually get rash either)
42
What investigations?
``` Malaria film / ICT: x 2 over 2 days FBC, U&E, LFTs, CRP 2 sets blood cultures Serology EDTA for PCR e.g. Dengue Urinalysis Stool CXR ```
43
Causes of lymphopenia. (4)
Viral, Dengue, Typhoid, HIV
44
Causes of low-normal WCC. (4)
Malaria, Viral, Typhoid, Rickettsial
45
Causes of neutrophilia. (2)
Bacterial, Amoebic
46
Causes of thrombocytopenia. (4)
Malaria, dengue, typhoid, sepsis
47
Causes of eosinophilia?
Schisto, Fasciola, Filaria, Strongyloides, drug reaction
48
How may patients with malaria present?
Patients may present with non-specific ‘flu-like illness / sore throat / diarrhoea
49
Gold standard for malaria diagnosis.
Thick and thin blood film
50
When might parasiteaemia by low?
If taking prophylaxis (or pregnant)
51
What do rapid diagnostic tests (RDTs) detect?
Plasmodium spp. antigens
52
Markers of severe malaria (Plasmodium falciparum).
``` Parasitaemia ≥ 10% Cerebral involvement - impaired consciousness, seizures Respiratory involvement - ARDS, pulmonary oedema Shock Bleeding / DIC / platelets <20 Anaemia: Hb <8 Hypoglycaemia: <2.2 mmol/L Renal failure: oliguria, creat >265mol/L Haemoglobinuria Acidosis (pH <7.3) ```
53
How is severe/complicated P. falciparum treated?
IV Artesunate (preferred) OR IV Quinine (cardiac & blood glucose monitoring) Oral therapy as for uncomplicated once improved Check blood film daily
54
Other indications for IV therapy. (3)
- Parasitaemia >2% or presence of schizonts - Vomiting - Pregnancy (get specialist advice)
55
How is uncomplicated P. falciparum treated?
``` Oral therapy with either - Malarone (Atovaquone-Proguanil) - Riamet (Artemether-lumefantrine; artemesinin combination therapy – ACT) - Quinine & Doxy / Clinda ```
56
How is non falciparum treated?
Chloroquine followed by primaquine - check G6PD status
57
How many arboviruses (arthropod-borne viruses) are there? | What are the most common in returning travellers?
> 500 | Dengue and Chikungunya
58
Arboviruses - only some cause disease in humans and most are self-limiting. How can they present?
Can present as systemic febrile illness, haemorrhagic fever, encephalitis or arthritis or a combination of these.
59
What is the incubation period for dengue?
3-14 days
60
How is dengue transmitted?
Day-biting Aedes spp. mosquitos
61
Spectrum of dengue illness.
Spectrum of illness ranges from mild febrile illness to haemorrhagic fever and shock. Classically have febrile illness with headache, myalgia, arthralgia and rash which is initially erthyrodermic and later becomes petechial.
62
Global incidence of dengue per year. | Where do epidemics occur?
50-100 million cases per year | Asia and South America
63
Warning signs of dengue.
``` Abdo pain or tenderness Persistent vomiting Clinical fluid accumulation Mucosal bleed Lethargy, restlessness Liver enlargement >2cm Lab: increase in HCT concurrent with rapid decrease in platelet count ```
64
Probable dengue.
``` Fever and two of the following: Nausea, vomiting Rash Aches and pains Leukopenia Any warning sign Tourniquet test positive ```
65
Severe dengue.
Severe plasma leakage Severe haemorrhage Severe organ impairment
66
How is dengue treated?
Simple analgesia (avoid NSAIDs) Monitor patients with warning signs Daily FBC - ↑haematrocrit, ↓platelets Careful fluid balance
67
What is the incubation period for chikungunya?
1-12 days
68
Where was Chikungunya first described?
East Africa but now in much of South and East Asia, parts of Europe, and South America / Caribbean
69
How does Chikungunya present? How is it diagnosed? How is it treated?
Fever and severe arthralgia – arthritis may develop and last for months Diagnosis by PCR or IgM Symptomatic relief, steroids for refractory arthritis
70
Typhoid and Paratyphoid (Enteric Fever) - what is it caused by? What is the incubation period? How does it present?
Salmonella Typhi or Paratyphi 1-3 weeks Fever is almost always present but other symptoms are non-specific and may include headache, constipation/ diarrhoea and dry cough.
71
Complications of enteric fever.
Complications in 10-15% include GI bleeding, intestinal perforation and encephalopathy. Life threatening in 3%.
72
Is vaccination effective against enteric fever?
Vaccination is only partially effective against typhoid and ineffective against paratyphoid.
73
How is enteric fever diagnosed?
FBC may be normal, but decreased white cells and platelets common. Blood culture : 40-70% sensitive Stool & urine culture Widal test unreliable (esp in endemic areas)
74
How is enteric fever treated?
Widespread reduced susceptibility to ciprofloxacin Empirical treatment with IV ceftriaxone while awaiting sensitivity results Sensitive organisms may be treated with oral ciprofloxacin Azithromycin can also be used to treat non-complicated disease Patient must be isolated while in hospital and notified
75
What is the incubation period of rickettsia?
5-10 days
76
How is rickettsia treated?
Empirically treat with Doxycycline | Alternative treatments include azithromycin
77
What are the different types of rickettsia?
``` African tick bite fever Rocky mountain spotted fever Endemic (murine) typhus Epidemic typhus Scrub typhus ```
78
African tick bite fever - pathogen and vector.
R. africae | Tick
79
``` African tick bite fever - geographical distribution. Rash? Eschar? Lymphadenopathy? Case fatality rate? ```
``` Sub-Saharan Africa and Caribbean ++ ++ ++ Self-limiting ```
80
Scrub typhus - pathogen, vector, geographical distribution.
O. tsutsugamushi Larval mite “chigger” Southeast Asia, Far East, W. Pacific, N. Australia
81
``` Scrub typhus: Rash? Eschar? Lymphadenopathy? Case fatality rate? ```
++ ++ ++ 10%
82
Give some differentials for undifferentiated fever in the returning traveller.
``` Malaria Enteric fever Dengue / Chik Rickettsiae Acute schistosomiasis Leptospirosis Amoebic liver abscess Brucella ```
83
Differentials for fever + respiratory symptoms.
``` Sinusitis, tonsillitis, bronchitis Influenza Pneumonia Tuberculosis Legionella Rarely: novel coronaviruses (MERS, SARS), melioidosis (mainly from South East Asia) ```
84
Differentials for fever + jaundice.
``` Hepatitis A-E Malaria Leptospirosis Enteric fever Yellow fever Non-typhoidal Salmonella & HIV Typhus EBV, CMV Relapsing fevers VHF Sepsis Haemolytic-uremic syndrome Haemolysis Sickle cell crisis ```

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