Fever in the Returned Traveler

1
Fever in the Returned Traveler

• Capt Joshua Latham
• D.O.
• Family Medicine (PGY-3)
• 19 March 08 1000 - 1045

2
Objectives

• Identify the most common causes for fever in the
  returning traveler
• Understand how timing and geographical history
  assist in establishing a differential
• Recognize some physical exam clues to augment the
  history
• Improve your knowledge base of a few important
  infectious causes for fever

3
IT TAKES 43 MUSCLES TO FROWN AND 17 TO SMILE, BUT
IT DOESNT TAKE ANY TO JUST SIT THERE WITH A DUMB
LOOK ON YOUR FACE
4
Resources

• CDC
• - www.cdc.gov
• - http//wwwn.cdc.gov/travel/contentYellowBook.asp
  x
• Armed Forces Medical Intelligence Center
• - www.afmic.detrick.army.mil
• GIDEON
• - www.gideononline.com
• AAFP
• - www.aafp.org

5
Illness among travelers to developing world

• 22-64 self report health complaints
• 8 seek medical care
• per year
• 50 million travelers
• 4 million visits

6
GeoSentinel
Clinical Infectious Disease 2007
7
Diagnoses among returning travelers
(Freedman et al. NEJM 2006 GeoSentinel Data)

• 4 major categories comprise 2/3 illnesses

8
Fever(Wilson et al. Clin Inf Dis 2007
GeoSentinel Data)

• CC in 28 of over 24,000 pts
• Broken down by syndromes
• 35 systemic febrile illness
• 15 febrile diarrheal illness
• 14 respiratory illness
• 22 undifferentiated

9
Fever etiology(Wilson et al. Clin Inf Dis
2007 GeoSentinel Data)

• Overall
• 1 overall
• MALARIA
• Systemic febrile illness
• - Malaria
• - Dengue
• - Enteric Fever
• - Rickettsial diseases

10
Evaluation

• History, History, History
• PE
• Supporting lab work
• Expert consultation when indicated
• Identify signs requiring urgent intervention

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A Broad Differential

• Fever unrelated to travel
• - common things being common
• Travel related non-infectious
• - thrombophlebitis, PE, drug fever
• Infectious considerations
• - en-route exposures
• - geographic considerations
• - in-country exposures

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Essential History (5 Ws)

• Who
• Where
• What
• When
• Why

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WHO

• The patient
• Age/sex, PMH, Medications
• - may affect MM
• Vaccinations/hx of infections
• - various efficacy of vaccinations
• - susceptibility

14
WHO

• The patient (cont)
• preparations for travel
• - pre-travel clinic
• - prophylaxis and protections used
• Other travelers
• similar exposures?
• - foods, events, locations
• symptomatic?
• - same illness, different sx, timeframe

15
NEVER UNDERESTIMATE THE POWER OF STUPID PEOPLE IN
LARGE GROUPS
16
WHERE

• Geographic and specific destinations
• - narrows differential
• Accommodations
• - living quarters
• - water supply
• Travel plans
• - type of transport
• - layovers/intermediate stops

17
Geographic Considerations (Freedman et al. NEJM
2006 GeoSentinel Data)
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Geographic Considerations (Freedman et al. NEJM
2006 GeoSentinel Data)

• Sub-Saharan Africa
• - prioritize malaria
• - include rickettsial infections in DDx
• Southeast Asia
• - think dengue, then malaria
• - remember possible mefloquine resistance
• South Central Asia
• - Suspect typhoid and paratyphoid

19
Geographic Considerations (Freedman et al. NEJM
2006 GeoSentinel Data)
20
Geographic Considerations (Freedman et al. NEJM
2006 GeoSentinel Data)

• Central and South America
• - malaria and dengue most prominent
• - cutaneous leishmaniasis and myiasis
  (non-febrile)
• - bartonellosis (Andes mountains)
• Caribbean
• - dengue, then malaria
• - cutaneous larval migrans (non-febrile)

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Accommodations and Exposures

• Quarters
• - urban vs rural
• - availability of protection from creatures
• Water
• - contaminated drinking sources
• - bathing water

22
Infections acquired during Travel

• Transmission during travel can occur
• - Influenza, TB, SARS
• Risk factors include
• - duration of exposure
• - proximity
• - severity of source pt
• - ventilation system
• Consider all areas visited

23
WHAT

• Exposures
• Foods
• Activities
• Encountered critters

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Exposures

• Water
• Fresh - lepto, schisto, hep A, melioidosis,
  enteric bacteria
• Salt Water - vibrio, hep A
• Animals
• Cattle, Sheep - brucella, coxiella, anthrax,
  tularemia
• Rodents - hantavirus, lassa fever, typhus
• Cats/Dogs - rabies, pasteurella, bartonella, toxo
• Humans
• Sexual - STIs, HIV, hepatitis
• Non-sexual - TB, measles, diphtheria, varicella

25
Exposures

• Foods
• Raw stuff
• - tape worms (meats)
• - ascariasis, liver flukes (vegetables)
• - lung/intestinal flukes (fish, crustaceans)
• Unpasteurized dairy
• - brucella, coxiella, listeria
• Insects
• Mosquitoes, flies, sand flies
• - malaria/dengue, yellow fever, arboviruses,
  filariasis, leishmaniasis, Oroya fever,
  babesiosis
• Ticks, fleas, mites, lice
• - rickettsial diseases, typhus, relapsing fevers,
  plague

26
IT COULD BE THAT THE PURPOSE OF YOUR LIFE IS ONLY
TO SERVE AS A WARNING TO OTHERS
27
WHEN

• Dates of travel
• - seasons/climate
• Duration of stay
• - period of exposure
• Onset of symptoms
• -incubation periods and clinical course

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Timing Length of Stay

• Brief exposure
• - arthropod borne illnesses and ingestion of
  contaminated foods

• Prolonged exposure
• - filarial and some helminthic infections

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Incubation Period lt 2 weeks

• Malaria
• Dengue
• Rickettsial Infections
• Leptospirosis
• Typhoid
• Paratyphoid
• Brucellosis
• Melioidosis
• African Trypanosomiasis

• Meningococcemia
• Viral encephalitis
• Hemorrhagic fevers
• Tularemia
• Relapsing fever
• Polio
• Angiostrongylus
• Rabies
• Acute HIV

(Suh, Kozarsky, Keystone. Med Clin North Am 1999)
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Incubation Period 2-8 weeks

• Malaria
• Leptospirosis
• Typhoid
• Paratyphoid
• Brucellosis
• Melioidosis
• Trypanosomiasis

• Hemorrhagic fevers
• Liver abscess
• Toxoplasmosis
• Hepatitis A E
• Schistosomiasis
• Q-fever
• Oroya fever

(Suh, Kozarsky, Keystone. Med Clin North Am 1999)
31
Incubation Period gt2 months

• Malaria
• Melioidosis
• Liver abscess
• Rabies
• Hepatitis B

• Visceral Leishmaniasis
• Tuberculosis
• Lymphatic filariasis
• Fascioliasis

(Suh, Kozarsky, Keystone. Med Clin North Am 1999)
32
Highlights of Timing

• gt60 of dengue seen lt 1 wk
• gt90 P. falciparum malaria lt1 month
• gt50 P. vivax/ovale malaria gt1 month
• gt1/3 hepatitis A gt6 wks
• Most severe, life-threatening infections are
  apparent within 3 months

33
WHY

• Reason for travel
• Vacation
• Mission/medical work
• Visiting friends/relatives
• - less seek pretravel medical advice
• - greater risk for vaccine-preventable illnesses
• - more likely to get fever

34
JUST BECAUSE YOUVE ALWAYS DONE IT THAT WAY
DOESNT MEAN ITS NOT INCREDIBLY STUPID
35
Take Home for History

• Narrow differential with thorough history
• Timing and Location are highest yield
• Visitors friends/relatives increased risk
• Life-threatening infections lt 3 months

36
Physical Exam

• Recognize signs for urgent intervention
• Perform thorough exam
• Combine your history and PE to refine the
  differential

37
Indications for Urgent Intervention

• Respiratory Distress
• Hypotension/hemodynamic instability
• Confusion, lethargy, stiff neck, focal neurologic
  findings
• Hemorrhagic manifestations

38
Interventions

• Supportive care and stabilization as indicated
• Consider empiric medication therapy
• - IV anti-malarials broad spectrum antibiotics
• - oral medications to consider
• Malarone/Mefloquine
• Doxycycline
• FQ
• Continue attempts to identify etiology

39
PE Clues

• VS
• relative bradycardia - typhoid, rickettsial dz
• Skin
• maculopapular rash - dengue, lepto, typhus
• eschar - rickettsial dz
• rose spots - typhoid
• petechiae - meningococcemia, VHF, dengue

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Eschar
41
Rose Spots
42
PE Clues

• ENT
• injected conjunctiva - leptospirosis, VHF
• common infxns - AOM, sinusitis, strep pharyngitis
• Abdomen
• splenomegaly - malaria, mono, typhoid,
  brucellosis, lepto

43
PE Clues

• Lymphadenopathy
• localized - TB, MAC, plague, typhus,
  trypanosomiasis, filariasis
• generalized - brucellosis, lepto, TB,
  melioidosis, dengue, leish (visceral)

44
PE Clues

• Pulmonary
• URI/LRI - influenza, legionella
• parenchymal involvement - TB, VHF, helminths,
  protozoa
• Neurological
• AMS - meningococcal, malaria, entero and
  arboviruses, typhoid, rickettsial, lepto
• eosinophilic meningitis - angiostrongylus

45
Routine Labs

• CBC with differential
• Liver enzymes
• - AST, ALT, AP
• Liver function tests
• - coags, alb, platelets
• Blood cultures
• Blood smears

Thick and thin blood smears Q 12-24 hrs x 72 hrs
46
Other tests if indicated

• Stool cultures, WBCs, O/Ps
• CXR or other imaging
• Lumbar puncture
• Biopsies
• Serologies

47
Evaluation Summary

• Start broad on the differential
• Narrow differential using the 5 Ws
• Identify when urgent intervention is needed
• Utilize PE to strengthen suspicion
• Augment H/P with appropriate lab tests

48
NO MATTER HOW GREAT AND DESTRUCTIVE YOUR PROBLEMS
MAY SEEM NOW, REMEMBER, YOUVE PROBABLY ONLY SEEN
THE TIP OF THEM
49
Malaria

• Protozoa Plasmodium (4 species)
• 300 800 million new infections yearly
• 1-3 million deaths per year
• Incubation typically 7-30 days
• Systemic febrile illness

50
Malaria

• Diff dx 1,2,3 in traveler with fever
• Diagnosis is made by blood smear
• - performed q 12-24 hrs x 72 hrs if suspected
• Concerning factors
• - altered mental status (GCS lt11)
• - gt10 parasitemia
• - gt5 neutrophils with pigment
• - hypoglycemia
• - pulmonary edema

51
Treatment of Malaria

• Treatment based on species and resistance
• - http //www.cdc.gov/malaria/pdf/treatmenttable.p
  df
• Hospitalization
• - falciparum malaria
• - severely ill
• - undetermined speciation
• Severe/cerebral malaria
• - ICU
• - parenteral therapy (quinidine, chloroquine)
• - no evidence of benefit from steroids

EBM (LOE C) Prasad, Garner. Cochrane Review
1999.
52
Dengue (Break-bone fever)

• flaviviruses
• Aedes mosquito (day biters)
• Incubation 3-14 days
• Systemic febrile illness
• - retro-orbital pain, backache
• - rash noted in 50
• - hemorrhage, shock

53
Dengue

• Diagnosis primarily clinical
• - serologies available
• Hemorrhagic fever
• - previously infected patients
• - mortality increases with shock
• Treatment is supportive
• - aggressive fluid hydration
• - blood, FFP, etc.
• - ASA is contraindicated
• - No benefit from steroids

EBM (LOE C) Panpanich et al. Cochrane Review
2006.
54
Enteric Fever

• Typhoid/Paratyphoid fever (101)
• Salmonella typhi and paratyphi
• Incubation 5-21 days
• Systemic febrile illness
• - constipation, abdominal pain
• - rose spots (30-50)
• - relative bradycardia

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Enteric Fever

• Diagnosis
• - blood, urine cultures
• - bone marrow culture most sensitive
• Treatment
• - oral cipro 500mg x 7-10 days
• - IV Ceftriaxone 2g/day x 7-10 days
• - dexamethasone for AMS
• - may treat for schistosomiasis
• Prevention
• - vaccine available (50-80 effective)

EBM (LOE C) Aberdein J. Crit Care 2006.
56
Viral Hemorrhagic Fever Manifestations

• Systemic febrile illness
• - fever, HA, abdominal pain, sore throat,
  myalgias and diarrhea
• More suggestive of VHF
• - pharyngitis, conjunctivitis, rash
• - hemorrhage and shock

57
Recommendations for Suspected VHF (CDC)

• Initial evaluation
• - standard precautions are acceptable
• Upon hospitalization
• - isolation
• - contact and droplet precautions
• - avoid all contact with bodily fluids
• Airborne precautions
• - advanced stages
• - cough, vomiting, diarrhea, or hemorrhage

58
Recommendations for Suspected VHF (CDC)

• Reduce exposure
• - avoid percutaneous injuries
• - minimize lab draws
• - disinfect contaminated surfaces
• - dispose of linens properly
• - minimal handling of corpse
• Exposure
• - immediately wash surface/wound with soap and
  water
• - copious irrigation of mucous membranes

59
MAY NOT BE WARRANTED AT THIS POINT
60
What we learned

• Always think malaria with fever
• When it comes to travel history
• - Location, location, location
• - Timing is everything
• Identify need for intervention and seek
  additional help
• Fine tune the history with your PE
• Swift diagnosis and treatment is paramount
• - with ill patients, consider empiric therapy
• When it comes to motivational sayings

61
IF A PRETTY POSTER AND A CUTE SAYING ARE ALL IT
TAKES TO MOTIVATE YOU, YOU PROBABLY HAVE A VERY
EASY JOB. THE KIND ROBOTS WILL BE DOING SOON.
62
References

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• CDC. Health Information for International Travel
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  Heymann. Washington DC, USA American Public
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  Spectrum of disease and relation to place of
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63
References

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64
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