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Tropical problems in the returning traveller

Tropical problems in the returning traveller. Ravi Gowda Infection and Tropical Medicine UHCW May 2011. Outline. An approach to the ill returning traveller in 10 mins Application of this approach to clinical cases Mini picture quiz. Why is this subject important in Coventry?.

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Tropical problems in the returning traveller

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  1. Tropical problems in the returning traveller Ravi Gowda Infection and Tropical Medicine UHCW May 2011

  2. Outline • An approach to the ill returning traveller in 10 mins • Application of this approach to clinical cases • Mini picture quiz

  3. Why is this subject important in Coventry?

  4. Coventry’s ethnic diversity2001 census

  5. World travel • Students • 2 universities • Coventry college • Lecturers • Elective students: medics, nurses • Visiting family and friends

  6. An approach to the febrile patient – 4 questions in 10 mins Where? When? Why? What?

  7. An approach to the febrile patient – 4 questions in your 10 mins Where? When? Why? What?

  8. Where? Details of travel Malaria endemic country? Yellow fever only occurs in Africa and South America Dengue and Chikungunya in SE Asia (Fever, arthralgia and rash: FAR)

  9. Where? • Was the area urban or rural? • Forested, or high altitude? • For example, transmission of malaria is less likely at altitudes over 2000 metres.

  10. An approach to the febrile patient – 4 questions in your 10 mins Where? When? Why? What?

  11. When? When did they go? When did they return? When did the symptoms start? Was it the rainy season? Increased risk of vector borne diseases Allows calculation of incubation periods

  12. SHORT (<10 days) Arboviral infections eg Dengue,chikungunya Gastroenteritis Typhus (louse and flea borne) Plague Viral Haemorrhagic fever Incubation period of common infections

  13. Incubation period of common infections MEDIUM 10-21 - Malaria - Enteric fever - Scrub typhus - African trypanosomiasis - Brucellosis - Leptospirosis

  14. Incubation period of common infections LONG (>21 days) - Viral hepatitis - Malaria - TB - HIV - Schistosomiasis - Visceral leishmaniasis - Filariasis - Amoebic liver abscess

  15. When? Helps to work out incubation periods If onset of symptoms starts >21 days after return, most imported infections ruled out except… HIV Malaria TB Leishmaniasis Chronic Schistosomiasis

  16. An approach to the febrile patient – 4 questions in your 10 mins Where? When? Why? What?

  17. Why? Did they go for sex? Whom did they have sex with?

  18. An approach to the febrile patient – 4 questions in your 10 mins Where? When? Why? What?

  19. What? Did the traveller going to a refugee camp as a humanitarian aid worker …. or attend a game reserve?

  20. What? The level of risk from diseases will vary greatly depending upon the type of terrain and facilities available Package holiday? Low risk

  21. What vaccinations and prophylaxis? • Effective • Hep A • Hep B • Japanese encephalitis • Yellow fever • Partially effective • Typhoid • TB • Malaria prophylaxis

  22. Exposure and Tropical infections • Raw/undercooked foods • enteric infections, hepatitis, trichinosis • Fresh water swimming • schistosomiasis, leptospirosis

  23. Exposure and Tropical infections • Insect bites • malaria, rickettsial infections, dengue, trypanosomiasis • Animal - Q fever, anthrax, rabies • Human - viral haemorrhagic fever

  24. Clinical Syndromes • Fever, rash, arthalgia (FAR) - arboviral infections, dengue. <10 days • Fever, rash, sore throat, lymphadenopathy - HIV seroconversion illness, EBV, streptococcal pharyngitis

  25. Physical signs aiding diagnosis • Jaundice • malaria, hepatitis, leptospirosis, yellow fever, glandular fever • Hepatomegaly • malaria, hepatitis, leptospirosis, typhoid, brucella

  26. Physical signs aiding diagnosis • Eschar • tick typhus, Crimean-Congo Haemorrhagic Fever, anthrax • Haemorrhage • Viral haemorrhagic fever, yellow fever, dengue, rickettsial infections (eg Rocky mountain spotted fever)

  27. New Eng J Med 2009

  28. Initial screen puo • FBC,ESR, U+E, LFTS,CRP, (blood cultures) • Malaria Film • Urine, stool (ova, cysts and parasites, M+C+S) • CXR

  29. Initial tropical eosinophilia screen • FBC,ESR, U+E, LFTS,CRP, • Urine for Schistosomiasis (if applicable) • 3 stools for ova, cysts and parasites, M+C+S • CXR • Serology for schistosomiasis, strongyloides, filiariasis, amoebiasis, hydatid

  30. Causes of fever in the returning Traveller

  31. Awareness of geographical distribution of infections

  32. Yellow fever risk areas-Africa Nathnac.org

  33. Case 1 • 85 yr old caucasian • 2/52 fever, sweats and wt loss • PMH - nil • Where? • rural Portugal, Algarve • Malta

  34. Case 1 • When • Portugal 4 months ago • Malta 20 yrs ago • 2 Weeks

  35. Case 1 • What and Why? • Villa holiday. Walking in surrounding countryside • Went with his longstanding wife • Hb.9.6 wcc 2.6Plt 50 • Bone marrow • ‘Myelodysplasia’

  36. Case 1 • Leishmania serology positive • Leishmania pcr positive in bone marrow • Diagnosis • Visceral leishmaniasis

  37. Leishmaniasis - Life cycle lifecycle

  38. Global distribution of leishmaniasis

  39. Leishmania- key messages • Think of leishmaniasis in any patient with a fever >2 wks and a hepato-splenomegaly…. • and has lived or travelled in an endemic area

  40. Case 2 • 54yr old lady admitted with 3/7 headache and fever. Admitted last week • Where? • India (Mumbai, Gujarat), Fiji • When? • July/August 2010 • Returned end of August

  41. Case 2 • Why? • Denies any risky behaviour • What? • Visiting friends and relatives, and tourist sites • Malaria prophylaxis (chloroquine) • Hx and exam. NAD

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