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Important Problems on Returning from the Tropics

Important Problems on Returning from the Tropics. Bruno Bernardin MD, FRCP, CSPQ. Objectives. Learn to recognize this presentation ... Learn to recognize this rash … Learn when and where to hide from patients Learn when to call funeral pre-arrangements Who’s toast, who’s not. Objectives.

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Important Problems on Returning from the Tropics

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  1. Important Problems on Returning from the Tropics Bruno Bernardin MD, FRCP, CSPQ

  2. Objectives • Learn to recognize this presentation ... • Learn to recognize this rash … • Learn when and where to hide from patients • Learn when to call funeral pre-arrangements • Who’s toast, who’s not

  3. Objectives • What is NOT malaria • Why is the epidemiology of infectious diseases changing • Recognize the most dangerous illnesses you can come across and prevent a disaster • Build a differential diagnosis from syndromic approach (as you may rarely come across these entities) • Maybe a few other goodies...

  4. Case 1: return of the prodigal son • Young man, 27 y.o., returned x 36 hrs from Cameroun where he visited his family x 1 mo • Fever, chills, malaise, apetite loss • Normal physical exam, To 39o, non toxic

  5. Case -2: Asia • Presents post trip to Thailand-Vietnam • Sore throat, dry cough, headache, myalgias, malaise, fever… • Exam non specific, some lymph nodes

  6. Case-3 • Patient returns from Middle East (or new immigrant) • Cough, wheezing, SOB • New onset asthma, in crisis • Better with B-agonists • CBC: eosinophilia

  7. Syndromes • Fever: • Hemorragic manifestations : • Transmissible: Ebola, Marburg, Lassa, Congo-Crimean • Non transmissible: yellow fever, HD • Respiratory manifestations • Neurological manifestations • Symptoms non specific: dengue, typhoid, malaria • With eosinophilia • Diarrhea • Hematuria • Cutaneous manifestations

  8. Fever in a traveler • 3% of travelers • Focus on life threatening, treatable, or transmissible • Incubation period may allow to eliminate certain pathologies: • >21 days = NOT dengue, viral hemorragic, ricketsioses...

  9. Small exercise: Typical picture : • fever, malaise • myalgias, headache • chills, anorexia • nausea, vomiting • +/- diarrhea DIAGNOSIS??

  10. Tropical fever : initial approach

  11. Hemorragic Fevers • Initial approach : isolate, isolate, isolate… • Differential diagnosis : • meningococcemia • gram negative sepsis • viral (not in the sense: “it’s just a virus, it’ll pass”)

  12. Hemorragic Fevers • 18 viruses identified • 4 have person to person transmission • Short incubation period • History of a trip (or contact having travelled!) • Increase in vascular permeability universal • Hemorragic component not universal!!

  13. Hemorragic Fevers • Ebola • Marburg • Dengue • Yellow fever • Lassa • Congo-Crimean

  14. Ebola - Filoviridae • 4 sub-types: • 3 pathogenic in humans: African strains • 1 pathogenic in monkeys: Reston • Reservoir: unknown • Region: RDC-Zaire, Soudan, Gabon, Côte-d’Ivoire, Uganda • Transmission: direct contact (sweat glands), biological fluids • aerosol: only for Reston • nosocomial +++

  15. Ebola- 2 • Sudden onset : To, myalgias, sore throat, headache, asthenia ++, No-Vo-diarrhea • Hemorragic manifestations: day 5-7 • Conjonctival injection, rash • Death in shock • Viral replication in and damage to vascular endothelium , hepatic destruction • Mortality: 50-88%

  16. Congo-Crimean - Bunyaviridae • Most widely spread HF in the world: Eastern Europe to the steppes of Asia, Africa, China • Transmitted by ixode tick bite or person to person via secretions (vomit, blood especially) • Low infectivity in nature • Farm workers : cows, sheep, milk

  17. Congo-Crimean • Sudden onset: To, myalgias (back), epiG pain • Conjonctivitis, hyperhemia pharynx, soft palate petechiae • Hemorrhage 3rd-5th day: hematuria, ecchymoses +++, oral, GI • Plt < 20 000, PT >60 s, AST >200, ALT >150: BAD!! • Tx: ribavirin

  18. Lassa - Arenaviridae • West Africa : Nigeria to Guinee • South America: Venezuela, Argentina, Bolivia (other viruses) • Transmission: secretions form contaminated animals (rodents) • humans: blood, secretions • 1 illness : 4-5 infected; • lethality 2-3%, 20-30% pregnant women!

  19. Lassa • Onsetinsidious: To, weakness, malaise; arthralgias, lombar pain • Dry cough, chest pain, Vo-diarrhea; pharyngitis • Bleeding: only 15-20%, oral especially • Oedema of face and neck or high LFT’s: BAD! • Ribavirin could decrease mortality

  20. Yellow Fever - Flaviviridae • Virus amaril • Transmission: mosquito bite • Reservoirs: monkeys in forest, humans in city • Important increase of cases recently • introduction of the vector and of the virus • decrease of vaccination spleen • rural exodus • abandon of moquito control programs

  21. Cycle Aae Rm Asp Savanne Ville Forêt Aaf* H H H

  22. Yellow Fever • 1 illness : 5-20 infected • 2 phases: acute viremic and toxic • 10-20% patients progress to toxic phase: • triad jaundice, hemorrhage, proteinuria • Mortality 15-20% of severe cases

  23. Yellow fever: acute phase • Incubation: 3-6 days, sudden onset • To, myalgias (back), headache, chills, anorexia, No-Vo • Conjonctivitis, strawberry tongue • Possible early jaundice • Decrease of symptoms, probable resolution (>80% of cases)

  24. Yellow fever: toxic phase • Remission < 24 hrs • Hepatic insufficiency : jaundice, dark urines • spontaneous bleeding (nose-mouth-GI), petechiae • coagulopathy, CIVD • encephalopathy • Renal failure : oliguria • Myocardial damage: • arrythmias, heart failure

  25. Fever and CNS manifestations • Cerebral malaria (falciparum) • Meningococcal meningitis • Typhoid • Rickettsiae • Viral encephalitis (WNV, JE, ticks) • Rabies • African trypanosomiasis (tse-tse)

  26. Fever and respiratory manifestations • Common pathogens • TB • Fever-pneumonia-hepatitis: Q fever • Helminths • Cough: malaria, typhoid, dengue…whatever!

  27. Non Hemorragic Fever • Risks: country, zone, activities • Length of stay, date of return • Vaccination (hepatitis, yellow fever) • Prophylaxis • Symptoms there and treatment (partial?) • Pattern of fever: degree, periodicity

  28. Typical Picture • Fever, malaise, headache • Chills, anorexia • Myalgias • Nausea, vomiting • Diarrhea DIAGNOSIS??

  29. Non Hemorragic Fever Consider and Rule Out Malaria!

  30. Fever: is it malaria? • If travel in malaria endemic zone • 35% malaria • 25% unknown source • 40% infectious cause or other non infectious • Falciparum: 90% onset of Sy < 1 month • Vivax: 50% onset Sy <1 month (2% >1 yr!)

  31. What are the other possibilities?

  32. Malaria Meningococcemia Dengue Hepatitis Amebiasis Shistosomiasis Filiariasis Typhoid Leishmaniasis Leptospirosis Non Hemorragic Fever

  33. Non Specific Fevers • Meningococcemia: • extremely prevalent in certain african regions, frequent epidemics • Hepatitis: • endemic in all parts of the world: • serotype (A,B,C, E) depends on region travelled, activities: food washed with non treated water or not peeled, sexual contacts...

  34. Dengue • Fever, myalgias, headache, retro- orbitalpain • Rash (transient), lymphadenopathy: 50% • Leukopenia, thrombocytppenia • Nausea, vomiting • Altered taste, skin hyperesthesia

  35. Pays with hemorragic dengue

  36. Dengue-2 • Epidemics, seasonal variations • Transmission by mosquito bite : Aedes aegypti • Flavivirus: 4 serotypes --> immunity specific to the type • Crossed immunity : short, incomplete

  37. Dengue-3: clinical syndromes • Non specific fever (especially kids) • Influenza syndrome : classic dengue • Hemorragic dengue (HD) • Dengue shock syndrome (DSS): high mortality

  38. Dengue: 2 phases • Viral syndrome • The fever abates (3rd-5th day) • Apparition of the morbiliform rash • Possible development of hemorragic manifestations • Recrudescence of the fever

  39. criteria: - spontaneous bleeding - plts < 100 000 - incr Hct >20% - ascites,pleural effusion - 20-30% of patients with DHF - mortality w/o Tx: 50%

  40. Dengue • Diagnosis: • clinical especially in PVD • convalescent antibody titers • Treatment: supportive! • especially fluids, APAP • Vasopressors if needed • Intensive care for HD, DSS group • < 1% mortality if appropriate Tx for DH- DSS

  41. Typhoid • Drinking or eating contaminated water/food • Salmonella typhi survives for long time in milieu • Most cases: imported: India, Philippines, South America • 1-4% of non-treated infected patients become chronic carriers

  42. Typhoid - 2 • 10-20% transient diarrhea at onset • Sudden fever, increasing gradually • Persistence of fever 3-4 weeks • Abdo pain, constipation • Maculopapular rash (rose spots), coated tongue

  43. Typhoid - complications • Intestinal perforation : 1-2% • Hemorrhage GI: 15% • Myocarditis: 1-5% • Cholecystitis: 1-2% • Septic arthritis, osteomyelitis, endocarditis, meningitis, abcess • Mortality: < 1% especially if Tx

  44. Typhoid: Dx and Tx • Stool cultures : sensitivity 30-40% • Blood cultures: 50-70% • Duodenal sampling: 60-80% • Marrow aspiration : 80-95% • TMP SMX, ampicillin, PCeph3, fluoroquinolone • Steroids for patients in shock or coma

  45. Leptospirosis • Swamp fever • Bacteria --> animals and humans • Exposure to water, soil, or food contaminated by urines of infected animals, via skin lesion or mucosae • Climate: temperate-tropical and North America

  46. Leptospirosis - 2 phases • 1st, septicemic: viral illness, conjonctivitis; lasts 4-7 days • 2nd, immune: meningitis, ARF-hepatic, ARDS • icteric form : severe: hepatic necrosis, coagulopathy, hepatic dysfonction: Weil syndrome

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