Fever in the returning traveller

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

2. Aims To provide a practical initial approach to the diagnosis and management of febrile adult returning from abroad.

3. Objectives • To be able to understand the importance of the topic • To be able to take a direct related history • To be able to correlate incubation period with most likely diagnosis • To be able to identify diagnosis that you can’t miss • To be able to “call a friend” if you are not sure

4. Objectives • To be able to understand the importance

5. Why do you think it is important?

6. Coventry’s ethnic diversity

7. World travel • Students • 2 universities • Coventry college • Lecturers • Elective students: medics, vets • Visiting family and relatives • Holiday

8. Aetiology of fever after travel to tropics

9. Objectives • To be able to understand the importance • To be able to take a direct related history

10. History • Brief • Directed • Workout timescales • Then you can calculate incubation periods and group likely causes • Bonus points if you find something on examination

11. “5 W questions” • Who? • What? • Where? • When? • Why?

12. “5 W questions” • Who? • What? • Where? • When? • Why?

13. Who? – risk factors • Travellers • Sub-Saharan • TB • HIV • Homosexual • HIV • Viral Hepatitis • South Asian? • TB • I know this might sound prejudiced but use it is an aid memoire

14. “5 W questions” • Who? • What? • Where? • When? • Why?

15. What? • Occupation • Farmer recently died of listeria at UHCW • Sewerage workers and leptospirosis • Activities • Ramblers and tick bites eg. Lyme disease • Animal contact

16. “5 W questions” • Who? • What? • Where? • When? • Why?

17. Where? • Details of travel • Malaria endemic country? • www.cdc.gov

18. “5 W questions” • Who? • What? • Where? • When? • Why?

19. When? • When did they go? • When did they return? • When did the symptoms start?

20. Objectives • To be able to understand the importance • To be able to take a direct related history • To be able to correlate incubation period with most likely diagnosis

21. Incubation period • Short (<10 days) • Medium (10-21 days) • Long (>21 days)

22. Short (<10 days) • Gastroenteritis

23. Medium 10-21 days • Malaria • Enteric fever

24. Long (>21 days) • Viral hepatitis • Malaria • TB • HIV

25. “5 W questions” • Who? • What? • Where? • When? • Why?

26. Why? (travellers) • Did they go for sex? • Whom did they have sex with? • Package holiday? • Low risk

27. Objectives • To be able to understand the importance • To be able to take a direct related history • To be able to correlate incubation period with most likely diagnosis • To be able to identify diagnosis that you can’t miss

28. Key diagnoses not to miss • Malaria • Enteric fever • HIV • TB • Because if missed they can result in… • Death • Chronic disability

29. Malaria • Originated probably form animal Malaria in central Africa • Spread around the world by human migration • 500 million people infected every year • Holoendemic (most people infected) Sub-saharan Africa > 75 % rate Transmission all year round 75% of the deaths are in children under 5 Adults significant immunity low parasitemia few symptoms

30. World-wide distribution

31. Malaria in the UK • Imported into the UK from tropical countries 1500-2000 cases reported each year 10-20 deaths

32. Human Malaria – 4 species • ¾ reported malaria cases in the UK are caused by Plasmodium falciparum, which can lead to life threatening multi-organ disease. • Most non-falciparum malaria cases are caused by Plasmodium vivax • Few cases are caused by Plasmodium ovale or Plasmodium malariae.

34. Clinical presentation • In non-immune individuals(children in any area, adults in hypoendemica area (0-10 % rate) and visitors to non- malarious region • Incubation 10-21 days (longer) • Symptoms: Malaise Fever (up to 41˚ C) Rigors Drenching sweats Vomiting or diarrhoea

35. P. vivax or P. ovale infection • Mild illness • Gradual anaemia • May be tender hepatomegaly • Recovery 2-4 weeks • Hypnozoites in liver can cause relapses for many years after infection • Chronic ill health due to anaemia and hyperactive splenomegaly

36. P. malariae infection • Mild illness but tends to run a more chronic course • In children can cause Glonerulonephritis and nephrotic syndrome

37. P. falciparium • Vast majority of malaria death are due to P. Falciparum • Patients deteriorate rapidly • Higher risk of bacterial infections • “Blackwater fever” is due to widespread intravascular haemolysis affecting parasitized and unparasitized red cell giving rise to dark urine

38. Specific and urgent investigation “Malaria parasites” • Thick (find it) • Thin (typify it) • Rapid antigen test Less sensitive for non falciparum No info about parasite count, maturity or mixed species Use in adjunct with microscopy

39. Major features of severe or complicated falciparum malaria in adults • Parasite count 2% or more • Impaired consciousness or seizures (cerebral malaria) • Renal impairment (oliguria < 0.4 ml/kg bodyweight per hour or creatinine > 265mmol/l) • Acidosis (pH < 7.3) • Hypoglycaemia (<2.2 mmol/l) • Pulmonary oedema or acute respiratory distress syndrome (ARDS) • Haemoglobin 8 g/dL • Spontaneous bleeding/disseminated intravascular coagulation • Shock (algid malaria e BP < 90/60 mmHg) • Haemoglobinuria (without G6PD deficiency)

40. Why high risk of hypoglycaemia in P falciparum malaria ?

41. Why high risk of hypoglycaemia? • Plasmodium use of glucose 75% greater than normal red cell • Quinine and Quinidine stimulates secretion of insuline • Associated to cerebral malaria > children and pregnant woman

42. Review Malaria algorithm

43. Key featuresMalaria • Malaria is a medical emergency and patients withsuspected malaria should be evaluated immediately • Return travellers with fever and any other symptoms • Geographical distribution ( beware of package holidays to the Gambia) • Think of relapse in the absence of recent travel

44. Enteric Fever • 16 million new cases worldwide mainly India and Africa • 600.000death per year • Typhoid is caused by Salmonella typhi Typical form of Enteric Fever • Paratyphoid is caused by Salmonella paratyphy A,B or C Less severe illness

45. Acute systemic illness: • Incubation period: 10-14 days • Food/water- borne • Symptoms: • Headache • Fever • Abdominal discomfort

46. Clinical Presentation of Enteric Fever Fever is almost invariable relative bradycardia only first week

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

48. 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

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

50. Treatment • Unstable treat empirically pending BCM • First choice: Ceftriaxone 2g iv • 70% of isolated S typhi and paratyphi imported into UK are resistant to Ciprofloxacin • In patients returning from Africa resistance 4% • If resistance to Ciprofloxacin: Azitromycin • NOTE: fever take some time to respond regardless of antibiotic use failure to defervesce is not a reason to change antibiotics if sensitive