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Fever in the returning traveller Part II

Fever in the returning traveller Part II. Dr Viviana Elliott Consultant Acute Medicine. Viral haemorrhagic Fever . Lassa fever RARE!!! Only VHF reported inUK Dengue Others Ebola Marburg Yellow fever Malaria: Plasmodium falciparum

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Fever in the returning traveller Part II

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  1. Fever in the returning traveller Part II Dr Viviana Elliott Consultant Acute Medicine

  2. 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

  3. Malaria • Should be thought in febrile illness in travellers returning to Europe from tropic Sub - Saharan Africa

  4. Malaria

  5. 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

  6. 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, U&Es, LFT and GLUCOSE • BCM for typhoid and other bacteriemia • Urine dipstick for haemoglobinuria and culture. Stool culture if diarrhoea • CXR to r/o CAP

  7. LaLaboratory diagnostic approach Diagnostic Approach FBC Eosinophils: helminth, drugs. Unlikely bacterial LFTs

  8. Falciparum Malaria or mixed infection

  9. Admit all cases and assess severity

  10. Complicated Malaria

  11. Treatment

  12. Enteric Fever(Typhoid and Paratyphoid)) • Commonest serious tropical disease from Asia • Distribution: worldwide in developing countries • Asia and south east Asia >100 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

  13. Clinical Presentation of Enteric Fever Fever is almost invariable Relative bradycardia only first week

  14. Clinical presentation of Enteric Fever • Constipation more common than diarrhoea initial loose stools fairly common • Maybe evanescent rash: “Rose spots”

  15. 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

  16. Complications • Incidence: 10-15% illness >2 weeks • GI Bleed • Intestinal perforation • Typhoid encephalopathy Vaccination provides incomplete protection

  17. 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

  18. Rickettsia: Common infection in travellers to games parks in southern Africa

  19. Ricketssias

  20. 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)

  21. R Conorii: single R Africae: multiple R Typhi

  22. 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

  23. 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 >100 countries and annual global incidence 50-100 million per year • Transmission: Aedes aegypty

  24. Clinical presentation • Mild febrile illness Headache- retro-orbital pain Myalgia - arthralgia (> 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

  25. Dengue 2 days later

  26. Dengue diagnosis and treatment • Positive PCR or if symptoms> 5-7 days +IgM ELISA • Retrospective > 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.

  27. 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

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

  29. 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

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

  31. Leptospirosis clinical presentation • Incubation : 7 – 12 days (range 2-30 days) • Initial phase: “flu like symptoms” lasting 4-7 days • Immune phase: “Weil’s disease” 1-3 days later fever, myalgia (calves) haepatorrenal syndrome haemorrhages Conjunctiva suffusions suggestive

  32. 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

  33. Investigations • Urinalysis proteinuria/haematuria • FBC PMN leucocytosis Thrombocytopenia Anaemia • Clotting normal (capillary fragility) • LFT high bili + mildly raised ALT • U&Es ARF • Serology IgM titre > 1:320 (early infection) > 10 days after symptoms send for IgM ELISA+ Microscopic agglutination MAT to confirm diagnosis

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

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

  36. Investigations • FBC neutrophil leucocytosis > 10 X 10 6 L • LFT dearranged ↑↑ Alk Pho • CRP/ESR raised • Indirect haemagglutination >90% sensitivity • Stools negative • CxR Raised hemi-diaphragm • USS DD piogenic abscess (percutanous aspiration) R/O Hydatidic disease first!

  37. Amoebic Liver abscess

  38. 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

  39. 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.

  40. 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

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

  42. 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 %

  43. 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

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