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Fever in the Returned Traveler

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... fatal and difficult to diagnose Take Home Points Febrile traveler = Malaria Dengue repeat infection may be fatal Leptospirosis and rickettsial infections ... – PowerPoint PPT presentation

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Title: Fever in the Returned Traveler


1
Fever in the Returned Traveler
  • Scott A. Wiltz, MD, MPH
  • Captain, USAF, MC
  • Eglin AFB Family Medicine Residency

2
Case History 1
  • 40 yo ADAF male with no significant PMH presents
    with fever, chills, sweats x 4 days

3
Case History 1
  • 40 yo ADAF male with no significant PMH presents
    with fever, chills, sweats x 4 days
  • Fever reached up to 103 F and comes in cycles
    every 5-6 hours.

4
Case History 2
  • ROS diarrhea (2-3 loose stools/day), anorexia,
    fatigue, mild headache (4 days) and mild,
    productive cough for 2 weeks.

5
Case History 2
  • ROS diarrhea (2-3 loose stools/day), anorexia,
    fatigue, mild headache (4 days) and mild,
    productive cough for 2 weeks.
  • Tobacco 20 pack-year, occasional EtOH

6
Case History 3
  • Pt is a special operations medic who was in
    Africa for 2 weeks on training mission and
    returned 5 days ago.

7
Case History 3
  • Pt is a special operations medic who was in
    Africa for 2 weeks on training mission and
    returned 5 days ago.
  • Seen yesterday and given levofloxacin for
    pneumonia

8
What next?
9
Take Home Points
10
Take Home Points
  • Febrile traveler Malaria

11
Take Home Points
  • Febrile traveler Malaria
  • Dengue repeat infection may be fatal

12
Take Home Points
  • Febrile traveler Malaria
  • Dengue repeat infection may be fatal
  • Leptospirosis and rickettsial infections may be
    fatal and difficult to diagnose

13
Take Home Points
  • Febrile traveler Malaria
  • Dengue repeat infection may be fatal
  • Leptospirosis and rickettsial infections may be
    fatal and difficult to diagnose
  • Early, empiric treatment

14
Take Home Points
  • Febrile traveler Malaria
  • Dengue repeat infection may be fatal
  • Leptospirosis and rickettsial infections may be
    fatal and difficult to diagnose
  • Early, empiric treatment
  • Doxycycline

15
Overview
  • Tropical Disease Basics

16
Overview
  • Tropical Disease Basics
  • Diagnostic Approach

17
Overview
  • Tropical Disease Basics
  • Diagnostic Approach
  • Red Flags

18
Overview
  • Tropical Disease Basics
  • Diagnostic Approach
  • Red Flags
  • Treatment

19
Overview
  • Tropical Disease Basics
  • Diagnostic Approach
  • Red Flags
  • Treatment
  • Pitfalls

20
BasicsMalaria
  • Plasmodium RBC parasite

21
BasicsMalaria
  • Plasmodium RBC parasite
  • falciparum, vivax, ovale, malariae

22
BasicsMalaria
  • Plasmodium RBC parasite
  • falciparum, vivax, ovale, malariae
  • Vector Anopheles spp

23
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24
BasicsMalaria
  • Plasmodium RBC parasite
  • falciparum, vivax, ovale, malariae
  • Vector Anopheles spp
  • Drug resistance varies by region

25
BasicsMalaria
  • Plasmodium RBC parasite
  • falciparum, vivax, ovale, malariae
  • Vector Anopheles spp
  • Drug resistance varies by region
  • Chloroquine, mefloquine, doxycycline,
    atovaquone/proguanil

26
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27
BasicsDengue
  • Viral infection

28
BasicsDengue
  • Viral infection
  • Breakbone fever

29
BasicsDengue
  • Viral infection
  • Breakbone fever
  • Almost always symptomatic

30
BasicsDengue
  • Viral infection
  • Breakbone fever
  • Almost always symptomatic

31
BasicsDengue
  • Viral infection
  • Breakbone fever
  • Almost always symptomatic
  • Repeat infection may present as VHF

32
BasicsDengue
  • Viral infection
  • Breakbone fever
  • Almost always symptomatic
  • Repeat infection may present as VHF
  • Vector Aedes spp.

33
BasicsDengue
  • Viral infection
  • Breakbone fever
  • Almost always symptomatic
  • Repeat infection may present as VHF
  • Vector Aedes spp.
  • Short incubation period (lt2 weeks)

34
BasicsLeptospirosis
  • Spirochete

35
BasicsLeptospirosis
  • Spirochete
  • Water-borne infection (animal urine)

36
BasicsLeptospirosis
  • Spirochete
  • Water-borne infection (animal urine)
  • Non-specific sxs (fever, diarrhea)

37
BasicsLeptospirosis
  • Spirochete
  • Water-borne infection (animal urine)
  • Non-specific sxs (fever, diarrhea)
  • Prophylaxis doxycycline q week

38
BasicsRickettsia
  • Arthropod-borne bacterial infection

39
BasicsRickettsia
  • Arthropod-borne bacterial infection
  • African tick painful bite

40
BasicsRickettsia
  • Arthropod-borne bacterial infection
  • African tick painful bite
  • Spotted fevers, meningitis

41
Diagnostic Approach
42
Diagnostic Approach
  • Hemorrhagic signs? Isolation?

43
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45
Diagnostic Approach
  • Hemorrhagic signs? Isolation?
  • HP, risk factors, red flags

46
Diagnostic Approach
  • Hemorrhagic signs? Isolation?
  • HP, risk factors, red flags
  • Suspect malaria

47
Geography Exposure
  • Be specific exact places and times

48
Geography Exposure
  • Be specific exact places and times
  • City vs rural

49
Geography Exposure
  • Be specific exact places and times
  • City vs rural
  • Living conditions

50
Geography Exposure
  • Be specific exact places and times
  • City vs rural
  • Living conditions
  • Vector exposure

51
Case Geography Exposure
  • Pt was in Niger on training mission

52
Case Geography Exposure
  • Pt was in Niger on training mission
  • Slept in a jungle bungalow

53
Case Geography Exposure
  • Pt was in Niger on training mission
  • Slept in a jungle bungalow
  • Remembers many mosquito bites

54
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58
Prophylaxis
  • Meds and compliance

59
Prophylaxis
  • Meds and compliance
  • Use of Personal Protective Equipment

60
Prophylaxis
  • Meds and compliance
  • Use of Personal Protective Equipment
  • Vaccinations

61
Prophylaxis
  • Meds and compliance
  • Use of Personal Protective Equipment
  • Vaccinations
  • Prior infections or exposures

62
CaseProphylaxis
  • Took doxycycline missed 2 days

63
CaseProphylaxis
  • Took doxycycline missed 2 days
  • Worked in insecticide treated uniform

64
CaseProphylaxis
  • Took doxycycline missed 2 days
  • Worked in insecticide treated uniform
  • Wore sandals and untreated clothes at night

65
CaseProphylaxis
  • Took doxycycline missed 2 days
  • Worked in insecticide treated uniform
  • Wore sandals and untreated clothes at night
  • yellow fever and typhoid vaccines

66
CaseProphylaxis
  • Took doxycycline missed 2 days
  • Worked in insecticide treated uniform
  • Wore sandals and untreated clothes at night
  • yellow fever and typhoid vaccines
  • No known prior travel-related infections

67
Case Summary
  • AF medic returned from Niger

68
Case Summary
  • AF medic returned from Niger
  • Significant exposure

69
Case Summary
  • AF medic returned from Niger
  • Significant exposure
  • Incomplete prophylaxis

70
RED FLAGS
71
Red FlagsNeuro
72
Red FlagsNeuro
  • Severe malaria

73
Red FlagsNeuro
  • Severe malaria
  • Coma, lethargy, delirium, seizures, retinal
    hemorrhages

74
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75
Red FlagsNeuro
  • Severe malaria
  • Coma, lethargy, delirium, seizures, retinal
    hemorrhages
  • Leptospirosis, Rickettsia

76
Red FlagsNeuro
  • Severe malaria
  • Coma, lethargy, delirium, seizures, retinal
    hemorrhages
  • Leptospirosis, Rickettsia
  • Severe HA, MS changes, seizure

77
Red FlagsNeuro
  • Severe malaria
  • Coma, lethargy, delirium, seizures, retinal
    hemorrhages
  • Leptospirosis, Rickettsia
  • Severe HA, MS changes, seizure
  • Dengue Shock Syndrome

78
Red FlagsNeuro
  • Severe malaria
  • Coma, lethargy, delirium, seizures, retinal
    hemorrhages
  • Leptospirosis, Rickettsia
  • Severe HA, MS changes, seizure
  • Dengue Shock Syndrome
  • Marked restlessness or lethargy, change from
    fever to hypothermia

79
Red FlagsPulmonary
80
Red FlagsPulmonary
  • Severe malaria

81
Red FlagsPulmonary
  • Severe malaria
  • Pulmonary edema, ARDS

82
Red FlagsPulmonary
  • Severe malaria
  • Pulmonary edema, ARDS
  • Leptospirosis

83
Red FlagsPulmonary
  • Severe malaria
  • Pulmonary edema, ARDS
  • Leptospirosis
  • Hemoptysis / pulmonary hemorrhage

84
Red FlagsHematologic
85
Red FlagsHematologic
  • Severe malaria

86
Red FlagsHematologic
  • Severe malaria
  • Anemia, hemolysis, thrombocytopenia, DIC

87
Red FlagsHematologic
  • Severe malaria
  • Anemia, hemolysis, thrombocytopenia, DIC

88
Red FlagsHematologic
  • Severe malaria
  • Anemia, hemolysis, thrombocytopenia, DIC
  • Dengue hemorrhagic fever

89
Red FlagsHematologic
  • Severe malaria
  • Anemia, hemolysis, thrombocytopenia, DIC
  • Dengue hemorrhagic fever
  • Plasma leakage hemoconcentration, ascites, or
    pleural effusion

90
Red FlagsHematologic
  • Severe malaria
  • Anemia, hemolysis, thrombocytopenia, DIC
  • Dengue hemorrhagic fever
  • Plasma leakage hemoconcentration, ascites, or
    pleural effusion
  • Plts lt 100K, spontaneous bleeding

91
Red FlagsHematologic
  • Severe malaria
  • Anemia, hemolysis, thrombocytopenia, DIC
  • Dengue hemorrhagic fever
  • Plasma leakage hemoconcentration, ascites, or
    pleural effusion
  • Plts lt 100K, spontaneous bleeding

92
Red FlagsHematologic
93
Red FlagsRenal
94
Red FlagsRenal
  • Severe malaria

95
Red FlagsRenal
  • Severe malaria
  • ARF, oliguria, hemoglobinuria

96
Red FlagsRenal
  • Severe malaria
  • ARF, oliguria, hemoglobinuria
  • Leptospirosis

97
Red FlagsRenal
  • Severe malaria
  • ARF, oliguria, hemoglobinuria
  • Leptospirosis
  • ARF with protein, granular casts, and WBCs

98
Red FlagsGI
99
Red FlagsGI
  • Severe malaria

100
Red FlagsGI
  • Severe malaria
  • Elevated LEs and bilirubin, hypoglycemia

101
Red FlagsGI
  • Severe malaria
  • Elevated LEs and bilirubin, hypoglycemia

102
Red FlagsGI
  • Severe malaria
  • Elevated LEs and bilirubin, hypoglycemia
  • Leptospirosis

103
Red FlagsGI
  • Severe malaria
  • Elevated LEs and bilirubin, hypoglycemia
  • Leptospirosis
  • Jaundice, hepatitis

104
Red FlagsLabs
105
Red FlagsLabs
  • Severe malaria

106
Red FlagsLabs
  • Severe malaria
  • Lactic acidosis especially poor prognosis

107
Red FlagsLabs
  • Severe malaria
  • Lactic acidosis especially poor prognosis
  • Parasitemia gt5 indicates severe disease

108
Red FlagsLabs
  • Severe malaria
  • Lactic acidosis especially poor prognosis
  • Parasitemia gt5 indicates severe disease

109
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116
CaseDiagnosis / Red Flags
  • CNS fatigue no lethargy or delirium
  • Heme Thrombocytopenia (Plts 86K)
  • Pulm cough (likely unrelated)
  • Renal Normal renal function
  • GI Elevated LEs / bilirubin
  • Lab Parasitemia 4-6

117
CaseDiagnosis / Red Flags
  • CNS fatigue no lethargy or delirium
  • Heme Thrombocytopenia (Plts 86K)
  • Pulm cough (likely unrelated)
  • Renal oliguria
  • GI Elevated LEs / bilirubin
  • Lab Parasitemia 4-6

118
Treatment
  • Severe malaria

119
Treatment
  • Severe malaria
  • Quinidine (doxycycline or clindamycin)

120
Treatment
  • Severe malaria
  • Quinidine (doxycycline or clindamycin)
  • Steroids ineffective for cerebral malaria

121
Treatment
  • Severe malaria
  • Quinidine (doxycycline or clindamycin)
  • Steroids ineffective for cerebral malaria
  • Dengue

122
Treatment
  • Severe malaria
  • Quinidine (doxycycline or clindamycin)
  • Steroids ineffective for cerebral malaria
  • Dengue
  • Aggressive supportive care

123
Treatment
  • Severe malaria
  • Quinidine (doxycycline or clindamycin)
  • Steroids ineffective for cerebral malaria
  • Dengue
  • Aggressive supportive care
  • Leptospirosis / Rickettsia

124
Treatment
  • Severe malaria
  • Quinidine (doxycycline or clindamycin)
  • Steroids ineffective for cerebral malaria
  • Dengue
  • Aggressive supportive care
  • Leptospirosis / Rickettsia
  • Doxycycline IV given early

125
CaseTreatment
  • ICU, IV hydration, neuro checks

126
CaseTreatment
  • ICU, IV hydration, neuro checks
  • Quinidine, doxycycline, mefloquine

127
CaseTreatment
  • ICU, IV hydration, neuro checks
  • Quinidine, doxycycline, mefloquine
  • Serial malaria smears, CMP, CBC

128
CaseTreatment
  • ICU, IV hydration, neuro checks
  • Quinidine, doxycycline, mefloquine
  • Serial malaria smears, CMP, CBC
  • Contacted the CDC

129
PitfallsMalaria
  • Serial smears

130
PitfallsMalaria
  • Serial smears
  • Parasite count RBCs vs parasites/µL

131
PitfallsMalaria
  • Serial smears
  • Parasite count RBCs vs parasites/µL
  • Severe malaria P. falciparum

132
PitfallsMalaria
  • Serial smears
  • Parasite count RBCs vs parasites/µL
  • Severe malaria P. falciparum
  • Pulmonary and GI sxs are common

133
PitfallsMalaria
  • Serial smears
  • Parasite count RBCs vs parasites/µL
  • Severe malaria P. falciparum
  • Pulmonary and GI sxs are common
  • Early treatment different from prophylaxis

134
PitfallsMalaria
  • Serial smears
  • Parasite count RBCs vs parasites/µL
  • Severe malaria P. falciparum
  • Pulmonary and GI sxs are common
  • Early treatment different from prophylaxis
  • Treat the parasite, not the sxs

135
PitfallsDengue
  • Biphasic fever curve (saddleback)

136
PitfallsDengue
  • Biphasic fever curve (saddleback)
  • DHF vascular permeability, low plts

137
PitfallsDengue
  • Biphasic fever curve (saddleback)
  • DHF vascular permeability, low plts
  • Subsequent infections more dangerous

138
PitfallsLeptospirosis / Rickettsia
  • Difficult to diagnose

139
PitfallsLeptospirosis / Rickettsia
  • Difficult to diagnose
  • IgM ELISA testing can support diagnosis, but is
    very slow

140
PitfallsLeptospirosis / Rickettsia
  • Difficult to diagnose
  • IgM ELISA testing can support diagnosis, but is
    very slow
  • High morbidity or mortality if not treated early

141
Take Home Points
  • Febrile traveler Malaria
  • Repeat dengue infection may be fatal
  • Leptospirosis and rickettsial infections may be
    fatal and difficult to diagnose
  • Early, empiric treatment
  • Doxycycline

142
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