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Fever in the Returned Traveler

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Identify the most common causes for fever in the returning ... Non-sexual - TB, measles, diphtheria, varicella. Exposures. Foods. Raw stuff - tape worms (meats) ... – PowerPoint PPT presentation

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Title: 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

11
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

12
Essential History (5 Ws)
  • Who
  • Where
  • What
  • When
  • Why

13
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)
18
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)

21
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

24
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

28
Timing Length of Stay
  • Brief exposure
  • - arthropod borne illnesses and ingestion of
    contaminated foods
  • Prolonged exposure
  • - filarial and some helminthic infections

29
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)
30
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

40
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

55
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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    systematic review of corticosteroid use in
    infections. Crit Care 2006 10203
  • Bottieau E, Clerinx J, Schrooten W, et al.
    Etiology and outcome of fever after a stay in the
    tropics. Arch Intern Med 2006 1661642-1648
  • CDC. CDC Surveillance Summaries, Malaria
    Surveillance United States, 2002. MMWR 2004
    5321-24
  • CDC. Health Information for International Travel
    2008. DHHS, Atlanta, GA
  • CDC. Management of patients with suspected viral
    hemorrhagic fever. MMWR 1988 371-15
  • CDC. Update management of patients with
    suspected viral hemorrhagic fever--United States.
    MMWR 1995 44475-479
  • Control of Communicable Diseases Manual. David L.
    Heymann. Washington DC, USA American Public
    Health Association, 18th (ed) 2004
  • Freedman DO, Weld LD, Kozrsky PE, et al.
    Spectrum of disease and relation to place of
    exposure among ill returned travelers. N Engl J
    Med 2006 354119-130

63
References
  • Guarda JA, et al. 1999. Malaria Re-emergence in
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    Accessed on 24 Feb 2008.
  • Huber J. 2003. Politically Correct. Available
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References
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