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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 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
World travel • Students • 2 universities • Coventry college • Lecturers • Elective students: medics, nurses • Visiting family and friends
An approach to the febrile patient – 4 questions in 10 mins Where? When? Why? What?
An approach to the febrile patient – 4 questions in your 10 mins Where? When? Why? What?
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)
Where? • Was the area urban or rural? • Forested, or high altitude? • For example, transmission of malaria is less likely at altitudes over 2000 metres.
An approach to the febrile patient – 4 questions in your 10 mins Where? When? Why? What?
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
SHORT (<10 days) Arboviral infections eg Dengue,chikungunya Gastroenteritis Typhus (louse and flea borne) Plague Viral Haemorrhagic fever Incubation period of common infections
Incubation period of common infections MEDIUM 10-21 - Malaria - Enteric fever - Scrub typhus - African trypanosomiasis - Brucellosis - Leptospirosis
Incubation period of common infections LONG (>21 days) - Viral hepatitis - Malaria - TB - HIV - Schistosomiasis - Visceral leishmaniasis - Filariasis - Amoebic liver abscess
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
An approach to the febrile patient – 4 questions in your 10 mins Where? When? Why? What?
Why? Did they go for sex? Whom did they have sex with?
An approach to the febrile patient – 4 questions in your 10 mins Where? When? Why? What?
What? Did the traveller going to a refugee camp as a humanitarian aid worker …. or attend a game reserve?
What? The level of risk from diseases will vary greatly depending upon the type of terrain and facilities available Package holiday? Low risk
What vaccinations and prophylaxis? • Effective • Hep A • Hep B • Japanese encephalitis • Yellow fever • Partially effective • Typhoid • TB • Malaria prophylaxis
Exposure and Tropical infections • Raw/undercooked foods • enteric infections, hepatitis, trichinosis • Fresh water swimming • schistosomiasis, leptospirosis
Exposure and Tropical infections • Insect bites • malaria, rickettsial infections, dengue, trypanosomiasis • Animal - Q fever, anthrax, rabies • Human - viral haemorrhagic fever
Clinical Syndromes • Fever, rash, arthalgia (FAR) - arboviral infections, dengue. <10 days • Fever, rash, sore throat, lymphadenopathy - HIV seroconversion illness, EBV, streptococcal pharyngitis
Physical signs aiding diagnosis • Jaundice • malaria, hepatitis, leptospirosis, yellow fever, glandular fever • Hepatomegaly • malaria, hepatitis, leptospirosis, typhoid, brucella
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)
Initial screen puo • FBC,ESR, U+E, LFTS,CRP, (blood cultures) • Malaria Film • Urine, stool (ova, cysts and parasites, M+C+S) • CXR
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
Yellow fever risk areas-Africa Nathnac.org
Case 1 • 85 yr old caucasian • 2/52 fever, sweats and wt loss • PMH - nil • Where? • rural Portugal, Algarve • Malta
Case 1 • When • Portugal 4 months ago • Malta 20 yrs ago • 2 Weeks
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’
Case 1 • Leishmania serology positive • Leishmania pcr positive in bone marrow • Diagnosis • Visceral leishmaniasis
Leishmaniasis - Life cycle lifecycle
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
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
Case 2 • Why? • Denies any risky behaviour • What? • Visiting friends and relatives, and tourist sites • Malaria prophylaxis (chloroquine) • Hx and exam. NAD