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Fever in the Returning Traveller - Coggle Diagram
Fever in the Returning Traveller
Epidemiology
10-42% of travellers to andy destination and 15-70% of travellers to tropical settings experience ill health
Immigrants visiting friends/ relatives are at high risk of infections
More than 70% of malaria cases in UK and USA and 90% of enteric fever in UK are attributable to people travelling to their country of origin
GI and resp symptoms are most common presentation with Fever
12-54% are ill enough to seek medical attention
1-6% hospitalised
Fever associated with severty of illness and hospital admission
Approach
Risk Evaluation
Pimary assessment for life-threatening condition
qSOFA score
Clinical Evidence of severe disease
Isolation
Preventative measures from suspicion of highly contagious disease to definite diagnosis
CLinical suspsicion of highly contagious disease
Viral haemorrhagic fever (VHF)
Middle east respiratory syndromes
Pnemonic plague
Avian influenza
Procedure
Spatial isolation
Use of PSE
Notification to local health authority
Trander to specialised centre where approapriate
History and Basicl Diagnostic Evaluation
Symptoms and Exposure focused history
Physical exam
Consideration of cosmopolitan disease
Paraclinical basic evaluation
Further diagnostic workup and management
After completeion of basic diagnostic workup without establishing a definite diagnosis
FEver of unknown origin in 1/3 of returning travellers
Malaria
Most common
Prevention
Insecticide treated nets
Prophylaxis in pregnant woman
Prophylaxis for children
Indoor residual spraying
Travel consultation
Destination
Location
Accomodation
Duration
Bite Prevention
Dawn and dusk bed nets
Clothing and mosquito repelland
Air conditioning
Prophylactic medication
Check species and drug susceptibilty of Destination
Atorvaquonen / Proguanil
Mefloquine
Doxycyline
Primaquine
Diagnosis
Gold standard: Blood films
Parasite density%, response to thereapy
Species, mixed infx
Rapid diagnostic tests
Antigens
Plasmodium pan-LDH, aldolase
P. Falciparum (Pf-)LDH< HRP-2
Negative results require smear confirmation
PCR
High Risk Groups
Pregnancy
Maternal mortality 50%
Placental malaria
Congenital malaria
Infants
HIV / AIDs
Increased parasite burdens
Possible decreased treatment response
ARV interactions: neutropaenia / hepatic
Clinical Features - Severe Malaria
Impaired conciousness
Seizures >3 ep in 24h
Respiratory distress / pulmonary oedema
Shock, systolic BP <70mm in adults <50mm in children
Spontaneous bleeding, haemoglobinuria
Co-Infections
Beacterial meningitis
Salmonella, UTI
Parasite schistosomiasis
HIV seroconversion illness
Cerebral malaria does NOT typically cause meningeal irritation
Labratory Findings
Biochem
Hypoglycaemia
Metabolic acidosis
Hyperlactaemia
Renal impairment
Jaundice - bili >43 mmol/L
Increased transaminases
Haem
Severe anaemia
Hyperparasitaemia
Treatment
Viral Haemorrhagic Fevers
Agents
Arboviruses
Flaviviruses
Mosquito borne
Yellow fever
Dengue
Bunyaviruses
Mosquito borne
Rift valley fever
Tick borne
Congo-crimean HF
Reoviruses
Tick borne
Colarado tick virus
Not Arboviruses
Bat viruses :bat:
Filoviruses
Ebola
Marburg
Rodent viruses :rat:
Bunyaviruses
Hantavirus
Arenaviruses
Lassa fever
South american VHF
Dengue Fever
Symptoms
Febrile phase
Sudden onset fever
Headache
Mouth and nose bleeding
Muscle and joint pains
Vomiting
Rash
Diarrhoea
Critical Phase
Hypotension
Pleural effusion
Ascites
GI bleeding
Recovery phase
Altered level of conciousness
Seizures
Itching
Slow heart rate
Epidemiology
Increasing incidence and mortality
Malaysia
Brazil
Yellow Fever
Clinical Illness
Acute phase
Toxic phase
Jaundice
Liver failure
Renal failure
Haemorrhagic fever
50% mortality within 2 weeks
Epidemiology
Nigeria
Brazil
Measles
Symptom timeline
Exposure to virus
10-12 days - fever
1-2 days later
Conjuctivitis
Coryza
Cough
Koplik's spots
1-2 days later
Rash on face, trunk, limbs
Contagious
4 days before rash-4days after appearance of rash
Complications
Otitis and hearing loss
Pneumonia
Death
Encephalitis
Bacterial Infections
Causes of Traveller's Diarrhoea
C. jejuni
Salmonella species
Shigella species
Bacteroides fragilis
Aeromonas
Pleisomonas
E. coli ETEC
Drug Resistance
VRE - Penicillin resistant pneumococcus Vancomycin resitant enterococcus
MRSA - Methicillin resistant staphlococcus aureus
ESBLs Extended spectrum beta-lactamase resistant enterobacteraciae
MDR TB - Multi drug resistant tuberculosis
XDR TB - EXtremely drug resistant tuberculosis
Carbapenamase-resistant enterobacteraciae
Plague in 21st Century
Western india
Madagascar
China
Re-Emergence of Old Bacterial Infx
Diphtheria
Russia
Cholera
Haiti
Sudan
Yemen
Somalia
DR Congo
Mozambique
Kenya
History Taking
WHO
Medical history
Drug history
Underlying immune suppression
Visiting friends / relatives
Traveller vs tourist
Special considerations in children and pregnant women
WHERE
Destination info as granular as possible
City / rural
Mountains / lakes / beaches
Accomadation
Last 12 months
REview sources for outbreaks
WHAT
What was patient doing abroad
Work - setting
Leisure activiues
Sexual contact
What and with whom
Hospital treatment or admission
Insect bites
Diet
WHEN
Review 12 months leading presentation
Before
Childhood vaccines
Malaria prophylaxis
Travel medicine appointments
During
Timeline for onset of symptoms
Malaria prophylaxis compliance
After
When was return
How have they been
Life-Threatening Tropical Infections
Viral
Avian influenze
MERS-CoV
Ebola viruse
Crimean-Congo haemorrhagic fever
Yellow fever
Severe dengue
Japanses encaphalitis
Rift valley fever
Rabies
Bacterial
Anthrax
Enteric fever
Epidemic typhus
Leptospirosis
Louseborne relapsing fever
Melioidosis
Murine or endemic typhus
Oroya fever or Carrion disease
Scrub typhus
Spotted fever group rickettsioses
Plague
Protozoan
East african sleeping sickness
Falciparum malaria
Knowlesi malaria
Examination
ABCDE
Cardiopulmonary exam
Abdominal exam
Neurology exam
Skin exam
Rashes
Bites
Eschars
Lymphadenopathy
Evidence of medical interventions
Investigations
Renal Function tests
FBC
Liver Function tests
Blood culture
Blood smears
For malaria should be sent urgently
Smear repeated 3 tims in 24-72 hrs
HIV test
Others
Guided by clinical syndrome
Respiratory viral swab
Urine dipstick
Urine microscopy
Urine culture
Urine culture and sensitivity
X-ray
Management
Infection Control Considerations
Diarrhoea or vomiting
Acute respiratory symptoms
Rash, wound or skin infections
Travel to a region endemic with viral haemorrhagic fever in last 21 days
Recet hospitalisation
Patient stabilisations
Treatment determined by diagnosis
Hospital admission - swab for resistant organisms especially in case of medical treatment abroad
Ebola Virus
Single stranded RNA virus of Filoviridae
Sub species
Zaire
Sudan
Ivory coast
Bundibugyo
Reston
Transmission
Exposure to bat secretions / excretions
Contacts with infected primates
Person to person / nosocomial
Category A bioterror agent (CDC)
Symptoms
Sonset 2-21 days from exposure
Fever
Headache
Mylagia
Weakness
Diarrhoea
Vomiting
Haemorrhagic fever
Subcutaneous, mucous membranes, orifices, internal
Septic shock, multi-organ failure
