Jungle Fever

1. Jungle Fever Phillip D. Levy, MD, MPH Associate Professor of Emergency Medicine Wayne State University/Detroit Receiving Hospital

2. Statement of Disclosure • I have no financial relationships relevant to this presentation

3. Purpose of This Talk • To provide a workable approach to the evaluation of “jungle fever” • Epidemiology • Symptomatology • To discuss basic principles of disease management • Pathophysiology • Treatment • Prevention

4. Focus Will Be Microbiology Not Sociology…

5. Why Bother ? • Some form of illness reported in 20-70 % of travelers 1,2 • Majority mild • Up to 8% seek medical care • 0.01-0.1% require medical evacuation • Overall mortality rate low (~ 0.001%) • ~ 3% experience fever 1 Ryan et al. NEJM 2002;347:505-16. 2 Freedman et al. NEJM 2006;354:119-30.

6. From: Freedman et al. NEJM 2006;354:119-30.

7. From: Freedman et al. NEJM 2006;354:119-30.

8. Potential Routes of Exposure • Inhalational • Ingestion • Fecal-oral • Infected foods (beef, pork, fish, snails, crabs, crayfish) or soil • Intravenous • Transdermal • Vector mediated • Mosquitoes, ticks, flies, mites, etc • Contact with contaminated soil or water

9. Aedes aegypti

10. Anopheles gambiae

11. General Approach • Historical clues • Location and duration of travel • Complete itinerary important • Incubation period • Associated symptoms • Diarrhea, abdominal pain • Cough, dyspnea • “Rash”, skin lesions • Arthralgias and myalgias • Mental status changes

12. Initial Work-Up • Blood smears • Thin and thick necessary • Giemsa stain preferred over Wright’s stain • Repeat testing Q 4-12h recommended until diagnosis is established • Blood cultures

13. Initial Work-Up • Complete blood count • Eosinophilia • Stimulated by IL-5 production • Highest values seen with migratory tissue helminthes • NOT seen with most protozoal infections • Isospora and Dientamoeba are exceptions • Anemia • Thrombocytopenia

14. Further Lab Evaluation • CSF analysis essential with potential CNS involvement • Urinalysis and culture • Fecal sampling • Fecal leukocytes • Limited sensitivity • Stool cultures, especially in pediatric patients • Stool O and P

15. Serology and Molecular Tests • Availability often limited • May have to contact CDC for selected organisms • Commercial kits exist for some protozoa • Cross-reactivity may limit full diagnostic utility • Sensitivity >>> specificity • Of limited value in individuals residing in endemic regions

16. Case # 1

17. “I’ve Got Jungle Fever” • 32 yo female presents to the ED with a rash, fever, headache, and bodyaches • Returned to the US 2 days ago after a 3 week trip to East Africa • BP 110/70 HR 130 RR 20 T 40° C • Diffuse lymphadenopathy • “Rash”

18. By the Numbers, Malaria is Most Likely…1 1 Leder et al. Clin Infect Dis 2004;39:1104-12.

19. Malaria • Plasmodium species: falciparum malariae, vivax, ovale • Cause of “fever” in ~ 40% of those with travel to endemic regions • For Africa: incidence ~ 2 % per month • Onset may be delayed (> 2 months) in up to 36 % 1 • Majority (84%)due to P. vivax • 67 % took “appropriate” chemoprophylaxis • 1 Schwartz wt al. NEJM 2003;349;1510-6.

24. Malaria Distribution From: Baird, J. K. NEJM 2005;352:1565-1577.

26. Image from: http://www.itg.be/itg/DistanceLearning/LectureNotesVandenEndenE/imagehtml/ppages/CD_1038_061c.htm

27. Dengue Fever • 50-100 million annual cases worldwide • 12,000 deaths • 4 different viral serotypes • Type 2 most virulent • Incubation period 4 – 7 days • Most manifest “typical” flu-like illness • Severe myalgias (aka “break-bone” fever) • 50% develop lymphadenopathy with maculopapular or petechial rash

28. Dengue Fever Distribution

29. Dengue Hemorrhagic Fever • Rare among travelers • Secondary manifestation • Results from immune system priming by prior infection with alternative strain • Produces enhancement of infection • Characterized by DIC-like picture • “Shock syndrome” may develop with induction of vascular permeability

30. Arthropod-borne Viruses • Flaviviridae • Yellow fever • Togaviridae • Chikungunya • O'Nyong-nyong fever • Bunyaviridae • Crimean-Congo fever • Rift valley fever

31. Related Non-Arboviruses • Arenaviridae • Lassa fever • Bolivian, Argentinean, Venezuelan HF • Bunyaviridae • Hantavirus • Filoviridae • Ebola, Marburg HF • Rhabdoviridae • Rabies virus

33. Typhus • Louse borne rickettsial infection • Epidemic (R. prowazekii) • Murine (R. typhi) • Incubation period 7-14 days • High fevers, headache, confusion, photophobia, vomiting, rash • Fatal in 10-60% • Symptoms may reoccur years later • Brill-Zinsser disease • Easy to treat with doxycycline

34. Other Rickettsial Infections • Spotted fevers (tick borne) • African tick-bite fever (R. africae) • Mediterranean (R. conorii) • Scrub typhus (mites) • Orientia tsutsugamushi • Painless eschar at innoculation site • Incubation 5-7 days • Fever, headache, myalgias, rash, lymphadenopathy • Treatment: doxycycline

35. Relapsing Fever • Spirochete infection • Tick borne (Borrelia spp.) • Louse borne (Borrelia recurrentis) • Incubation period 2-18 days • Fever (chill and flush), myalgias, arthalgias, rash • Episodes last 2-7 days • Cyclical recurrence every 4-14 days • Up to 10 times without treatment • Also treat with doxycycline • Jarisch-Herxheimer reaction in 50%

37. Typhoid FeverSalmonella typhi • 74% of cases in US linked to travel 1 • Incidence 3-30 per 100,000/month • Highest risk regions • India • Pakistan • Mexico • Bangladesh • The Philippines • Haiti 1 Steinberg et al. Clin Infect Dis 2004;39:186-91.

38. Typhoid Fever • Septicemia not gastroenteritis • Endotoxin-mediated SIRS • Greater inoculation = shorter incubation • Symptoms include fever, abd. pain, constipation • “Relative bradycardia” and “rose-spots” • Dx: stool, blood or bone marrow culture • Serologic test available, but less reliable

40. Tsetse Fly Glosinna sp.

41. African Trypanosomiasis • Trypanosomal chancre at bite site • Clinical illness divided • Stage I: Hemolymphatic only • Stage II: CNS invasion (“sleeping sickness”) • Early diagnosis by blood smear or biopsy • Found later in CSF • LP essential for ALL cases • Repeat at 2-4 months to assess treatment response

43. African Trypanosomiasis • Trypanosoma brucei • T. brucei rhodesiense (East Africa) • Fulminant course • T. brucei gambiense (West Africa) • Indolent course • Only 30 cases reported in US since 1967 1 1 Harris et al. NEJM 2002;346:2069-76.

44. African Trypanosomiasis Distribution

45. American Trypanosomiasis(Chagas’ Disease) • Trypanosoma cruzi • Reduviid bug • Chagoma at bite site • Fever, lymphadenopathy, hepatosplenomegaly • Chronic myocarditits and dysrrythmias • Megaesophagus/colon • Blood smear, xenodiagnosis or serology • Treatment: nifurtimox • 2-2.5 mg/kg po qid x 90-120 days • Not effective for chronic disease

46. Reduviid Bug Triatominae spp.

48. Meningococcal meningitis Endemic in certain regions of Africa Fatal if not treated…. Preventable by vaccination Other Conditions (not necessarily jungle related)

49. Case # 2

50. “She’s Got Jungle Fever” • A 27 yo female presents to the ED with fever, abdominal pain and intermittent diarrhea • Works for the Peace Corps • Just returned from Brazil after a 2 year assignment • BP 115/70 HR 120 RR 26 T 39.6º C • Abd. distended with RUQ tenderness • Stool heme (-)