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RCSI Royal College of Surgeons in Ireland Coliste Roga na Minle in irinn

The Returned Traveller, With Fever


HIV Clinical Presentation
Opportunistic
Class
Infections
IC2 Direct Entry
Course Tropical Medicine
Class
Code TM IC 2
Course
Date HLTM
8th September 2017
Code
Lecturer Prof Sam McConkey
Title Dr.
Lecturer Eoghan de Barra
Date 2014
Introduction
Between 20 and 70% of the 50 million people who travel
from the industrialized world to the developing world each
year report some illness associated with their travel.

Usually mild, self-limited illnesses


diarrhoea, respiratory infections, and skin disorders

1 to 5% become ill enough to seek medical attention


either during or immediately after travel, 0.01 to 0.1%
require medical evacuation, and 1 in 100,000 dies.

Ryan ET et al. N Engl J Med 2002;347:505-516.


Abdominal Abscess Mycoplasma Infections
Gout Chronic Myelogenous Leukemia
Actinomycosis Myocarditis
Graft Versus Host Disease Colon Cancer, Adenocarcinoma
Acute Lymphoblastic Leukemia Naegleria Infection
Graves Disease Coxsackieviruses
Acute Myelogenous Leukemia Neuroleptic Malignant Syndrome
Hairy Cell Leukemia Cryptococcosis
Adenoviruses Nocardiosis
Hepatitis A-E Cytomegalovirus
Adrenal Carcinoma Nonarticular Rheumatism/Regional Pain Syndrome
Hepatoma Cytomegalovirus Colitis
Adrenal Insufficiency Nonbacterial Prostatitis
Herpes Simplex Dengue Fever
Amebiasis Norwalk Virus
Histoplasmosis Diabetic Ulcers
Amebic Hepatic Abscesses Onchocerciasis
HIV Eastern Equine Encephalitis
Appendicitis Pancreatitis, Acute
Human Herpesvirus Type 6 Echoviruses
Arenaviruses Pelvic Inflammatory Disease
Hypersensitivity Pneumonitis Emphysematous Pyelonephritis
Aspergillosis Pericarditis, Acute
Hyperthyroidism Empyema, Gallbladder
Atrial Myxoma Pericarditis, Constrictive
Inflammatory Bowel Disease Empyema, Pleuropulmonary
Bacillary Angiomatosis Pericholangitis
Intra-abdominal Sepsis Enteroviruses
Bacteroides Infection Pharyngitis, Viral
Japanese Encephalitis Eosinophilic Pneumonia
Bartonellosis Pneumonia, Viral
Legionnaires Disease Epididymal Tuberculosis
Blastomycosis Prostatic Abscess
Leishmaniasis Epididymitis
Brain Abscess Psittacosis
Leptospirosis Epidural Abscess
Brucellosis Q Fever
Leukocytoclastic Vasculitis Erythema Multiforme (Stevens-Johnson Syndrome)
California Encephalitis Gastroenteritis, Viral
Libman-Sacks Endocarditis Giardiasis
Campylobacter Infections Other Problems to Be Considered
Listeria Monocytogenes Atypical mycobacterial infection
Candidiasis Clostridial necrotizing fasciitis
Liver Abscess Eosinophilic toxocariasis
Carcinoid Tumor, Intestinal Gallbladder gangrene
Lung Abscess Lyssavirus infection
Catscratch Disease Rhinocerebral phycomycosis
Lymphocytic Choriomeningitis Sphenoid sinusitis
Celiac Sprue Thrombophlebitis
Malaria Trypanosoma infection
Chagas Disease (American Trypanosomiasis) Osteomyelitis
Mastocytosis, Systemic Rat-bite fever (S minor)
Cholangitis Malassezia furfur infection
Mediterranean Fever, Familial C burnetii infection
Cholecystitis Malignant histiocytosis
Mediterranean Spotted Fever Drug fever
Choledocholithiasis Factitious fever
Meningococcemia Kikuchi disease
Chronic Bacterial Prostatitis
Miliary Tuberculosis
Chronic Lymphocytic Leukemia
Mucormycosis
Chronic Mesenteric Ischemia
Logical process
Infectious
Malignancy
Autoimmune
Iatrogenic
Thrombotic
Inherited
GeoSentinel sites
specialized travel or tropical-medicine clinics on six
continents
Collect clinicaian-based surveillance data on travel-related dx

Used for analysing patterns of disease


17,353 patients from June 1996 through August 2004
NEJM Freedman
Spectrum of Disease and Relation to Place of
Exposure among Ill Returned Travelers

David O. Freedman, M.D., Leisa H. Weld, Ph.D., Phyllis E. Kozarsky, M.D., Tamara
Fisk, M.D., Rachel Robins, M.D., Frank von Sonnenburg, M.D., Jay S. Keystone, M.D.,
Prativa Pandey, M.D. and Martin S. Cetron, M.D.

N Engl J Med
Volume 354;2:119-130
January 12, 2006
Study Overview

Some of the most common pathogens


identified were those causing malaria, dengue,
and rickettsial disease

The proportionate morbidity of various travel-


related infectious diseases was calculated
according to region of travel
Regions of Travel Exposure among Ill Travelers Returning from the Developing World

Freedman, D. et al. N Engl J Med 2006;354:119-130


Characteristics of Ill Travelers Returning from the Developing World, According to Region
Visited

Freedman, D. et al. N Engl J Med 2006;354:119-130


Disease diagnosis profiles for pediatric versus adult travelers, with adjustment for gender,
travel region, reason for travel, and travel duration.

Hagmann S et al. Pediatrics 2010;125:e1072-e1080

2010 by American Academy of Pediatrics


Diagnosis According to Syndrome Group and Travel Region among ill Travelers Returning
from the Developing World

Freedman, D. et al. N Engl J Med 2006;354:119-130


Conclusion
When patients present to specialized clinics after travel to the
developing world, travel destinations are associated with the
probability of the diagnosis of certain diseases

Examples from this study


Plasmodium falciparum malaria - sub-Saharan Africa (esp West
Africa)
Dengue in visitors to the Caribbean and Southeast Asia
Cutaneous leishmaniasis in those who visit Central America and
South America
Typhoid fever in travellers to south central Asia

Diagnostic approaches and empiric therapies can be guided


by these destination-specific differences
Distribution of regions of the world visited by ill travelers.

Wilson M E et al. Clin Infect Dis. 2007;44:1560-1568

2007 Infectious Diseases Society of America


Reports to GeoSentinel included in analysis of fever in returned ill travelers.

Wilson M E et al. Clin Infect Dis. 2007;44:1560-1568

2007 Infectious Diseases Society of America


Characteristics of returned ill travelers with and without fever (6957 patients with fever
among 24,920 ill returned travelers).

Wilson M E et al. Clin Infect Dis. 2007;44:1560-1568

2007 Infectious Diseases Society of America


Interval from return from travel to clinic presentation for patients who had fever, by specific
febrile illness.

Wilson M E et al. Clin Infect Dis. 2007;44:1560-1568

2007 Infectious Diseases Society of America


Summary of diagnosis groups and selected specific diagnoses in febrile patients after travel
(6957 patients with fever among 24,920 ill returned travelers).

2007 Infectious Diseases Society of America Wilson M E et al. Clin Infect Dis. 2007;44:1560-1568
Common Dermatologic Lesions in Travelers Returning from Developing Countries.

Ryan ET et al. N Engl J Med 2002;347:505-516.


Common or Important Infectious Diseases That May Cause Fever in Travelers,
According to Typical Incubation Period, Geographic Distribution, and Usual Mode of Transmission.

Ryan ET et al. N Engl J Med 2002;347:505-516.


History
Immunizations
Malaria treatment

Compliance

Reason for the trip


Duration
Compromised urban or Rural travel
Past medical history
History
History of symptoms, if
Exposures? any.
Swimming in freshwater?
Barefoot walking Broad review of systems
Trekking

Eating, drinking?
Bites?

Sex?

Other people sick?


4 biggest tropical causes of fever in
returning traveller
Symptoms
None

Systemic illness
fever or exanthem

Organ-specific illness
diarrhea, jaundice, or hepatosplenomegaly

Isolated laboratory finding


anemia or eosinophilia
Examination
Eyes
Mouth
Lymph nodes
Skin

Respiratory
Cardiovascular
Gastrointestinal
the sound of horses hooves..
but horses are far more comonright?
Consider non-travel conditions
Dont miss the obvious
Dont forget - routine
Pneumonia

UTI
Typical incubation periods for selected tropical infections

Short (<10 days) Long (>21 days)


Arboviral infections (including Viral hepatitis
dengue fever) Malaria
Enteric bacterial infections Tuberculosis
Typhus (louse borne, flea borne) HIV
Plague Shistosomiasis (Katayama fever)
Paratyphoid Amoebic liver abscess
Haemorrhagic fevers Visceral leishmaniasis
Filariasis

Medium (10-21 days)


Malaria
Typhoid fever
Scrub typhus, Q fever, spotted fever
group
African trypanosomiasis
Brucellosis
Leptospirosis
Lab tests
Initial "screening" tests:
Complete blood count
Blood smear for malaria parasites
Blood culture
Liver enzymes
Electrolytes; creatinine
Urine analysis
Stool culture,
ova and parasite exam
Acute phase serum

Ring Forms of Plasmodium falciparum.


Lab tests
Secondary tests:
Sputum exam and culture
Chest X-ray
Blood and bone marrow cultures
Hepatitis serology
Various serologies - targeted
Syphilis and HIV testing
Lumbar puncture
Endoscopy
Intravenous pyelogram
Ultrasound; CT/MRI scanning
Tissue biopsy
Tissue biopsy
Lymph node
Trypanosomiasis
Quadriceps biopsy
Trichinosis
Rectal biopsy
Schistosomiasis
Skin snips
Filariasis
Leprosy
Leishmania Leg Ulcer from Leishmania.

Hill DR. N Engl J Med 2006;354:115-117.


Remember
Incubation periods

Geographic risks
4 major syndromes
Fever
Diarrhoea
Eosinophilia
Rash
Fever
Malaria most important
Typhoid
Arbovirus dengue more likely outside Africa
Hepatitis A
Bacterial infections
Rickettsia

DONT FORGET HIV


[dont forget to consider TB]
Malaria
Most important infection to consider
Up to 40% do not report fever
Same day diagnosis
Repeat at least x 3 (sequestration)
Viral hepatitis
High risk in travellers from India, Middle east and Africa

Any increase in transaminase activity calls for a screen for


viral hepatitis
Case
Blessing
30 year old, Congolese woman
Lived in Ireland for last 4 years
Presents to A&E with a 3 day
Feverish
Sweats
Generally unwell
History
Returned 5 days ago from a trip home to Congo
Visiting Friends and Relatives
Eating, drinking, swimming
Well during trip.
On examination
37.5 C
Pulse 95 regular
BP 130/65
Resp rate 20, Sats 98% room air
General state
Eyes
Mouth
Lymph nodes
Skin

Respiratory
Cardiovascular
Gastrointestinal
Laboratory investigations
Hb 10.5 Urea 4
MCV 76 Na 135
WCC 7.2 K 3.6
Neutrophils 6.2 Creatine 98
Lymph 1.0
Platelets 57 Bili 45

ESR 50
CRP 35
Reassess our differential dx
Now consider diagnostic tests and treatments

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