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Fever in the returning traveller

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Title: Fever in the returning traveller


1
Fever in the returning traveller
  • Viviana Elliott
  • Consultant Acute Medicine

2
Aims
  • To provide a practical initial approach to the
    diagnosis and management of febrile adult
    returning from abroad.

3
Objectives
  1. To be able to understand the importance of the
    topic
  2. To be able to take a direct related history
  3. To be able to correlate incubation period with
    most likely diagnosis
  4. To be able to identify diagnosis that you cant
    miss
  5. To be able to call a friend if you are not sure

4
Objectives
  1. To be able to understand the importance

5
Why do you think it is important?
6
Coventrys ethnic diversity
Ethnic group
Total Population 300848 persons 100
White British 78.3
White Other 2.2
Indian 8
Pakistani 2.1
Black Caribbean 1.1
Black African 0.6
Black Other 0.1
Chinese or other ethnic group Chinese 0.7
7
World travel
  • Students
  • 2 universities
  • Coventry college
  • Lecturers
  • Elective students medics, vets
  • Visiting family and relatives
  • Holiday

8
Aetiology of fever after travel to tropics
Diagnosis MacLean et al (n597) Doherty et al (n195)
Malaria 32 42
Hepatitis 6 3
Respiratory infection LRTI- Bronchitis and Pneumonia 11 2.6
Urinary tract infection 4 2.5
Dengue fever 2 6
Enteric fever 2 2
Diarrhoeal illness 4.5 6.5
Epstein-Barr virus 2 0.5
Pharyngitis 1 2
Rickettsia 1 0.5
Amoebic liver abscess 1 0
Tuberculosis 1 2
Meningitis 1 1
Acute HIV 0.3 1
Miscellaneous 6.3 5
Undiagnosed 25 24.5 (viral and non specific infect)
9
Objectives
  • To be able to understand the importance
  • To be able to take a direct related history

10
History
  • Brief
  • Directed
  • Workout timescales
  • Then you can calculate incubation periods and
    group likely causes
  • Bonus points if you find something on examination

11
5 W questions
  • Who?
  • What?
  • Where?
  • When?
  • Why?

12
5 W questions
  • Who?
  • What?
  • Where?
  • When?
  • Why?

13
Who? risk factors
  • Travellers
  • Sub-Saharan
  • TB
  • HIV
  • Homosexual
  • HIV
  • Viral Hepatitis
  • South Asian?
  • TB
  • I know this might sound prejudiced but use it is
    an aid memoire

14
5 W questions
  • Who?
  • What?
  • Where?
  • When?
  • Why?

15
What?
  • Occupation
  • Farmer recently died of listeria at UHCW
  • Sewerage workers and leptospirosis
  • Activities
  • Ramblers and tick bites eg. Lyme disease
  • Animal contact

16
5 W questions
  • Who?
  • What?
  • Where?
  • When?
  • Why?

17
Where?
  • Details of travel
  • Malaria endemic country?
  • www.cdc.gov

18
5 W questions
  • Who?
  • What?
  • Where?
  • When?
  • Why?

19
When?
  • When did they go?
  • When did they return?
  • When did the symptoms start?

20
Objectives
  • To be able to understand the importance
  • To be able to take a direct related history
  • To be able to correlate incubation period with
    most likely diagnosis

21
Incubation period
  • Short (lt10 days)
  • Medium (10-21 days)
  • Long (gt21 days)

22
Short (lt10 days)
  • Gastroenteritis

23
Medium 10-21 days
  • Malaria
  • Enteric fever

24
Long (gt21 days)
  • Viral hepatitis
  • Malaria
  • TB
  • HIV

25
5 W questions
  • Who?
  • What?
  • Where?
  • When?
  • Why?

26
Why? (travellers)
  • Did they go for sex?
  • Whom did they have sex with?
  • Package holiday?
  • Low risk

27
Objectives
  1. To be able to understand the importance
  2. To be able to take a direct related history
  3. To be able to correlate incubation period with
    most likely diagnosis
  4. To be able to identify diagnosis that you cant
    miss

28
Key diagnoses not to miss
  • Malaria
  • Enteric fever
  • HIV
  • TB
  • Because if missed they can result in
  • Death
  • Chronic disability

29
Malaria
  • Originated probably form animal Malaria in
    central Africa
  • Spread around the world by human migration
  • 500 million people infected every year
  • Holoendemic (most people infected) Sub-saharan
    Africa
  • gt 75 rate
  • Transmission all year round
  • 75 of the deaths are in children under 5
  • Adults significant immunity
  • low parasitemia
  • few symptoms

30
World-wide distribution
31
Malaria in the UK
  • Imported into the UK from tropical countries
  • 1500-2000 cases reported each year
  • 10-20 deaths

32
Human Malaria 4 species
  • ¾ reported malaria cases in the UK are caused by
    Plasmodium falciparum, which can lead to life
    threatening multi-organ disease.
  • Most non-falciparum malaria cases are caused by
    Plasmodium vivax
  • Few cases are caused by Plasmodium ovale or
    Plasmodium malariae.

33
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34
Clinical presentation
  • In non-immune individuals(children in any area,
    adults in hypoendemica area (0-10 rate) and
    visitors to non- malarious region
  • Incubation 10-21 days (longer)
  • Symptoms
  • Malaise
  • Fever (up to 41 C)
  • Rigors
  • Drenching sweats
  • Vomiting or diarrhoea

35
P. vivax or P. ovale infection
  • Mild illness
  • Gradual anaemia
  • May be tender hepatomegaly
  • Recovery 2-4 weeks
  • Hypnozoites in liver can cause relapses for many
    years after infection
  • Chronic ill health due to anaemia and hyperactive
    splenomegaly

36
P. malariae infection
  • Mild illness but tends to run a more chronic
    course
  • In children can cause Glonerulonephritis and
    nephrotic syndrome

37
P. falciparium
  • Vast majority of malaria death are due to P.
    Falciparum
  • Patients deteriorate rapidly
  • Higher risk of bacterial infections
  • Blackwater fever is due to widespread
    intravascular haemolysis affecting parasitized
    and unparasitized red cell giving rise to dark
    urine

38
Specific and urgent investigation
  • Malaria parasites
  • Thick (find it)
  • Thin (typify it)
  • Rapid antigen test
  • Less sensitive for non falciparum
  • No info about parasite count, maturity or mixed
    species
  • Use in adjunct with microscopy

39
Major features of severe or complicated
falciparum malaria in adults
  • Parasite count 2 or more
  • Impaired consciousness or seizures (cerebral
    malaria)
  • Renal impairment (oliguria lt 0.4 ml/kg
    bodyweight per hour or creatinine gt 265mmol/l)
  • Acidosis (pH lt 7.3)
  • Hypoglycaemia (lt2.2 mmol/l)
  • Pulmonary oedema or acute respiratory distress
    syndrome (ARDS)
  • Haemoglobin 8 g/dL
  • Spontaneous bleeding/disseminated intravascular
    coagulation
  • Shock (algid malaria e BP lt 90/60 mmHg)
  • Haemoglobinuria (without G6PD deficiency)

40
Why high risk of hypoglycaemia in P falciparum
malaria ?
41
Why high risk of hypoglycaemia?
  • Plasmodium use of glucose 75 greater than normal
    red cell
  • Quinine and Quinidine stimulates secretion of
    insuline
  • Associated to cerebral malaria gt children and
    pregnant woman

42
Review Malaria algorithm
43
Key features Malaria
  • Malaria is a medical emergency and patients
    withsuspected malaria should be evaluated
    immediately
  • Return travellers with fever and any other
    symptoms
  • Geographical distribution ( beware of package
    holidays to the Gambia)
  • Think of relapse in the absence of recent travel

44
Enteric Fever
  • 16 million new cases worldwide mainly India and
    Africa
  • 600.000death per year
  • Typhoid is caused by Salmonella typhi
  • Typical form of Enteric Fever
  • Paratyphoid is caused by Salmonella paratyphy A,B
    or C
  • Less severe illness

45
Acute systemic illness
  • Incubation period 10-14 days
  • Food/water- borne
  • Symptoms
  • Headache
  • Fever
  • Abdominal discomfort

46
Clinical Presentation of Enteric Fever
Fever is almost invariable relative bradycardia
only first week
47
Clinical Presentation of Enteric Fever
  • Constipation more common than diarrhoea
  • initial loose stools fairly common
  • Maybe evanescent rash Rose spots

48
Investigations
  • First Week
  • Bloods low WBC, platelets and mildly raised
    LFTs
  • BCM positive 40-80
  • Second week
  • Urine culture 0-58
  • Stool culture 35-65
  • Bone marrow higher sensitivity than BCM
  • Newer rapid serology IgM against specific S Typhi
  • Widal test lacks sensitivity and specificity not
    recommended

49
Complications
  • Incidence 10-15
  • illness gt2 weeks
  • GI Bleed
  • Intestinal perforation
  • Typhoid encephalopathy
  • Vaccination provides incomplete protection

50
Treatment
  • Unstable treat empirically pending BCM
  • First choice Ceftriaxone 2g iv
  • 70 of isolated S typhi and paratyphi imported
    into UK are resistant to Ciprofloxacin
  • In patients returning from Africa resistance 4
  • If resistance to Ciprofloxacin Azitromycin
  • NOTE fever take some time to respond regardless
    of antibiotic use failure to defervesce is not a
    reason to change antibiotics if sensitive

51
Key featuresEnteric fever
  • Salmonella typhi
  • Food/water- borne
  • Especially South Asia travel
  • Any traveller with fever and headache returning
    in the last 21 days
  • Diarrhoea often absent or late in illness
  • Blood culture diagnosis
  • Septicaemia and death

52
Human Immunodeficiency Virus (HIV)
  • 40 million people are HIV and half of them are
    in Africa (WHO 2004)
  • HIV 1 (retrovirus) is responsible for most cases
    world wilde
  • HIV 2 related virus produces similar illness with
    longer latent period
  • 3 million have acquired immunodeficiency syndrome
    (AIDS)

53
Transmission
  • Sexual contact 75
  • Infected blood products
  • IV drug abuse
  • Perinatal

54
Stages of infection
  • Acute infection asymptomatic
  • Sero-conversion transient illness 2-6 weeks
    after HIV infection fever, malaise, myalgia,
    pharyngitis, maculopapular rash or
    meningngoencephalitis (rare)
  • Persistent generalised lymphadenopathy (PGL)
    nodes ? 1 cm and 2 extra-inguinal sites for ? 3
    months Opportunistic infections Candida, herpes
    zoster, tenia infections (AIDS related complex)

55
Key features HIV
  • Risk group
  • Recurrent infections
  • Herpes zoster
  • Oral candida
  • Persistent lymphadenopathy
  • Anaemia, leucopaenia, thrombocytopaenia

56
Key features TB
  • Risk group
  • Chronic systemic and respiratory symptoms
  • Unresolving symptoms, raised inflammatory markers
    and belonging to a risk group
  • Beware of protean manifestions

57
Objectives
  1. To be able to understand the importance
  2. To be able to take a direct related history
  3. To be able to correlate incubation period with
    most likely diagnosis
  4. To be able to identify diagnosis that you cant
    miss
  5. To be able to call a friend if you are not sure

58
Call a friend at UHCWThe Infection Tropical
Medicine Service
  • Dr Ravi Gowda in patients ward 31
  • GUM Consultant service 24/7 through switchboard
  • HIV clinics at the Coventry Warwickshire
    hospitals
  • General Infectious Diseases outpatient once a
    week (Tuesday am)
  • Joint TB clinic with Dr Dhillon (Tuesday pm)

59
Key points
  • Think of the 5 Ws
  • Risk factors for disease
  • Dont miss
  • Malaria (knowledge of travel)
  • Enteric fever (knowledge of travel)
  • HIV (risk group)
  • TB (risk group)

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61
Useful websites
  • www.britishinfectionsociety.org
  • www.who.int
  • www.hpa.org.uk
  • http//www.istm.org/geosentinel/main.html
  • Further reading
  • Fever in the returning traveller part II in
    website

62
Fever in the returning traveller Part II
  • Dr Viviana Elliott
  • Consultant Acute Medicine

63
Viral haemorrhagic Fever
  • Lassa fever RARE!!!
  • Only VHF reported inUK
  • Dengue
  • Others Ebola
  • Marburg
  • Yellow fever
  • Malaria Plasmodium falciparum
  • 5000 x common than Lassa fever!!!!!

Fever, rural area, likely contact, high fever ,
severe exudative sore throat, prostration out of
proportion with fever
64
Malaria
  • Should be thought in febrile illness in
    travellers returning to Europe from tropic

Sub - Saharan Africa
65
Malaria
66
Early diagnosis and assessment of severity is
vital to avoid deaths
  • Symptoms are non specific
  • Almost 50 are a febrile on presentation but all
    have history of fever
  • Consider country of travel, stopovers and date of
    return. Incubation at least 6 days and within 3
    months more with prophylaxis
  • Consider other infections Typhoid fever,
    hepatitis, dengue fever, avian influenza, SARS,
    HIV, Meningitis, Encephalittis and VHF

67
Urgent investigations
  • Thick (find it) and thin (typify it) and rapid
    antigen test ( less sensitive for non falciparum,
    no info about parasite count, maturity or mixed
    species. Use in adjunct with microscopy)
  • FBC Thrombocytopenia, UEs, LFT and
  • GLUCOSE
  • BCM for typhoid and other bacteriemia
  • Urine dipstick for haemoglobinuria and culture.
    Stool culture if diarrhoea
  • CXR to r/o CAP

68
LaLaboratory diagnostic approach Diagnostic
Approach
FBC
?WBC with neutrophils ? WBC with neutrophils ? WBC with lymphocytes
Pneumonia UTI Leptospirosis Brucella Typhoid Other Salmonella Viral Rickettsial
Eosinophils helminth, drugs. Unlikely bacterial
LFTs
Very High High bili Mod trans Renal disfunction
Viral hepatitis Yellow fever Toxin Leptospirosis
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70
Falciparum Malaria or mixed infection
71
Admit all cases and assess severity
72
Complicated Malaria
73
Treatment
74
Enteric Fever(Typhoid and Paratyphoid))
  • Commonest serious tropical disease from Asia
  • Distribution worldwide in developing countries
  • Asia and south east Asia
  • gt100 cases per 100.000 person per year
  • 77 in person visiting friends and family
  • Most cases occur 7 18 days after exposure
  • range 3-60 days

75
Clinical Presentation of Enteric Fever
Fever is almost invariable Relative bradycardia
only first week
76
Clinical presentation of Enteric Fever
  • Constipation more common than diarrhoea
  • initial loose stools fairly common
  • Maybe evanescent rash Rose spots

77
Investigations
  • First Week
  • Bloods low WBC, platelets and mildly raised
    LFTs
  • BCM positive 40-80
  • Second week
  • Urine culture 0-58
  • Stool culture 35-65
  • Bone marrow higher sensitivity than BCM
  • Newer rapid serology IgM against specific S Typhi
  • Widal test lacks sensitivity and specificity Not
    recommended

78
Complications
  • Incidence 10-15
  • illness gt2 weeks
  • GI Bleed
  • Intestinal perforation
  • Typhoid encephalopathy
  • Vaccination provides incomplete protection

79
Treatment
  • Unstable treat empirically pending BCM
  • First choice Ceftriaxone 2g iv
  • 70 of isolated S typhi and paratyphi imported
    into Uk are resistant to Cipro
  • In patients returning from Africa resistance 4
  • If resistance to Cipro, Azitromycin
  • NOTE fever take some time to respond regardless
    of antibiotic use failure to defervesce is not a
    reason to change antibiotics if sensitive

80
Rickettsia Common infection in travellers to
games parks in southern Africa
81
Ricketssias
Rickettsia Africae Conorii Typhi Orientia Tsusugamuyi
African tick bite fever Mediterranean spotted fever fever Murine typhus Scrub typhus from Asia
Transission Catle ticks Dog tick Rat fleas Mites
Distribution Sub-saharan African and safari park in southern Africa Eastern Caribean Mediterranean and Caspian Litoral, Middle East , Indian subcontinent and Africa Tropical and subtropical areas in port cities where the rodent population is dense Rural South Asia (Laos) South East Asia Western pacific Infrequently report by travellers
Complications Fatal 32 Fatal 2 If untreated Pneumonitis, CID,ARF and Meningoencephalitis
82
Common presentation
  • Incubation 5-7 days (up to 10 days)
  • Non specific fever, head ache , mialgia,
    inoculation echar/rash and lymphadenitis
  • Consider other causes of fever and skin lesions
    wich resembles echar
  • Antrax

African Trypanosomiasis (chancre at site of
tsetse fly bite)
83
R Conorii single
R Africae multiple
R Typhi
84
Investigations
  • Treatment should be started on suspicion
  • - illness onset within 10 days
  • - exposure to tick in game park
  • - fever and headache with or without
    rash
  • Doxycyxline 100 mg bd for 7 days or 48 hs after
    fever defervescence
  • Confimation IFA paired initial and convalescence
    phase serum sample
  • If wider differential is considered Cipro or
    Azithromycin

85
Arbovirus infection
  • Commonest arboviral infection in returning
    travellers to the UK are Dengue and Chikungunya
  • Incubation 4 8 days (range 3-14)
  • Distribution Asia and south America
  • Repoted gt100 countries and annual global
    incidence 50-100 million per year
  • Transmission Aedes aegypty

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87
Clinical presentation
  • Mild febrile illness
  • Headache- retro-orbital pain
  • Myalgia - arthralgia (gt back pain)
  • Rash 1st erythrodermic
  • 2nd petechial
  • Bleeding gums, epistaxis and GI bleed
  • Rarely hepatitis, myocarditis,
    encephalities
  • and neuropathies
  • Convalescence desquamation and post viral
    fatigue

88
Dengue 2 days later
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91
Dengue diagnosis and treatment
  • Positive PCR or if symptomsgt 5-7 days IgM ELISA
  • Retrospective gt 4 fold ? Ig G by
    haemoaglutination inhibition test
  • UK reference laboratory services HPA Special
    Pathogens reference Unit, Poton Down
  • Treatment identify those patients at high risk of
    shock with daily FBC and platelets.

92
Acute Schistosomiasis
  • Katayama fever
  • Incubation 4-6 weeks ( range 3-10 weeks)
  • Distribution Africa (Asia- South America)
  • Transmission Swimming in lakes or rivers
  • Cercariae release from snails penetrates intact
    skin

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95
Clinical presentation
  • Non specific signs and symptoms (? immune complex
    phenomenon)
  • fever myalgia arthralgia
  • lethargy cough/wheeze headache
  • rash ?Liver/spleen diarrhoea
  • Investigations
  • eosinophilia
  • egg urine-stools
  • minority serology seroconversion
  • 0-6 months)

96
Treatment
  • Diagnosis
  • Fresh water exposure 4-8 weeks previously
  • Fever-Urticarial rash-Eosinophilia
  • Treatment empiric!!!!
  • Praziquantel
  • 2 doses 20 mg/kg, 4-6 hs apart (Mature
    Schistosomes)
  • Repeat after 3 months ( Immature schistosomes)
  • Short course of Steroids may alleviate acute
    symptoms

97
Leptospirosis
  • Distribution Worldwide including UK
  • (gt tropical and subtropical regions)
  • Risk exposure to fresh surface water, rodents
    (infected urine)
  • sports events
  • river rafting
  • rescue efforts after flooding

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99
Leptospirosis clinical presentation
  • Incubation 7 12 days (range 2-30 days)
  • Initial phase flu like symptoms lasting 4-7
    days
  • Immune phase Weils disease
  • 1-3 days later
  • fever, myalgia (calves)
  • haepatorrenal syndrome
  • haemorrhages
  • Conjunctiva suffusions suggestive

100
Other manifestations
  • GI V-D, loss appetite, jaundice and
    hepatomegaly, liver failure, pancreatitis
    and GI bleed
  • Respiratory Cough SOB
  • Meningitis
  • ARF
  • Myocarditis
  • Haemorrages may confuse DHF

101
Investigations
  • Urinalysis proteinuria/haematuria
  • FBC PMN leucocytosis
  • Thrombocytopenia
  • Anaemia
  • Clotting normal (capillary fragility)
  • LFT high bili mildly raised ALT
  • UEs ARF
  • Serology IgM titre gt 1320 (early infection)
  • gt 10 days after symptoms send for IgM ELISA
    Microscopic agglutination MAT to confirm diagnosis

102
Treatment
  • Upon suspicion
  • Penicillin and tetracycline antibiotics during
    bacteraemia phase
  • Un well patients and Weils disease need renal
    and liver support
  • Severe diseases is probably immunologically
  • mediated ( ? Benefit from antibiotics)

103
Amoebic Liver Abscess
  • Incubation 8-20 weeks ( up to a year)
  • Distribution Worldwide gt developing
    countries
  • Presentation 67-98 Fever
  • 72-95 Abdominal pain
  • 43-93 Haepatomegaly
  • 20 PMH dysentery
  • 10 diarrhoea on diagnosis

104
Investigations
  • FBC neutrophil leucocytosis gt 10 X 10 6 L
  • LFT dearranged ?? Alk Pho
  • CRP/ESR raised
  • Indirect haemagglutination gt90 sensitivity
  • Stools negative
  • CxR Raised hemi-diaphragm
  • USS DD piogenic abscess (percutanous
    aspiration) R/O Hydatidic disease first!

105
Amoebic Liver abscess
106
Treatment
  • Start empiric treatment in patients with
    suggestive history, epidemiology and imaging
  • Metronidazole 500 mg tds orally for 7-10 days (
    Cure in 90)
  • Tinidazole 2 g daily for 3 days (less nauseas)
  • Follow treatment with 10 days luminal amoebicide
    to reduce relapse.
  • Furoate 500 mg tds or Paromomycin 30 mg/kg per
    day in 3 divided doses

107
Brucellocis
  • Incubation 2-4 weeks (up to 6 months)
  • Distribution world-wide ( Middle East, URRS,
    Balkan Peninsula and Mediterranean basin)
  • Transmission infected unpasteurised milk
    products. Farmers, vets with contact infected
    parts.

108
Clinical presentation
  • Fever Commonest presentation
  • acute with rigors or
  • chronic low grade relapsing
  • Lymphadenopathy
  • Hepatosplenomegaly
  • Complications
  • Osteoarticular disease
  • OA knees, hips, ankles and wrists
  • Sacroillitis lumbar spine

109
Other complications
  • Epididymo-orchitis
  • Septic abortions
  • Neurological meningitis encephalitis brain
    abcess
  • Endocarditis Aortic valve and requires early
    surgery

110
Investigations and treatment
  • LFT mild transaminitis
  • FBC pancytopenia
  • Bone marrow gold standard
  • BCM sensitivity 15-70 (prolong cultures up to 4
    weeks)
  • Note Q Fever, rarer, similar from same area
  • Serology is key diagnosis!!
  • Treatment Doxycycline and Rifampicin 6-8 weeks
    amynoglucosides 2 weeks
  • Relapse 10

111
HIV
  • Prevalence in tropical countries is high 1/3
    sexually active population and not restricted to
    high-risk groups
  • 5-51 travellers take part in casual sex while
    abroad
  • HIV seroconversion and syphilis can present as
    febrile illness

112
Hepatitis
  • Incubation A 15-50 days
  • B 60-110 days
  • E 14-70 days
  • Transmission A-E faecal-oral (water,
    foodshellfish and direct contact)
  • B sex-blood
  • Diagnosis IgM
  • Traetment Supportive

113
Fever an respiratory symptoms
  • Upper respiratory tract infection viral,
    St.Pneumonia, H Influenza, Grup A steptoccoi
  • Diphteria in traveller returning from URRS,
    India, South East Asia and South America
  • Lower respiratory tract infections
  • HIV related PCP
  • Bird flu
  • TB (prolonged visits to families and friends)
    Histoplasmosis/ Coccidioidomycosis risk
    activities with dust and bats in caves in America

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115
Initial treatment for bird flu
  • Isolate
  • Respiratory isolation ideally negative
    pressure
  • Samples NPA nasal swab PCR
  • Inform
  • Local ICT/Virology/ID
  • Regional HPA/CCDC
  • Treat Oseltamivir/Zanamavir

116
Fever and Neurological Symptoms
  • 15 per 1000 ill returned travellers
  • Most common Malaria and meningitis
  • Encephalopathy P falciparum,typhoid and HIV
    seroconversion
  • Encephalitis with or without fever
  • Common causes in UK
  • Arboviruses Brucellosis
  • Rabies Rickettsias
  • African trypanosomiasis
  • Discussion with virologist or reference laboratory

117
Key points
  • Think of the 5 Ws
  • Risk factors for disease
  • Dont miss
  • HIV (risk group)
  • TB (risk group)
  • Malaria (knowledge of travel)
  • Enteric fever (knowledge of travel)
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