Fever in the returning traveller Part II

Dr Viviana Elliott

Consultant Acute Medicine

Viral haemorrhagic Fever

Lassa fever RARE!!!

Only VHF reported inUK

Dengue

Others Ebola

Marburg

Yellow fever

Malaria: Plasmodium falciparum

5000 x common than Lassa fever!!!!!

Fever, rural area, likely contact, high fever ,

severe exudative sore throat, prostration out

of proportion with fever

Malaria• Should be thought in febrile illness in travellers

returning to Europe from tropic

Sub - Saharan Africa

Malaria

Early diagnosis and assessment of severity is vital to avoid deathsSymptoms are non specific

Almost 50% are a febrile on presentation but all have history of fever

Consider country of travel, stopovers and date of return. Incubation: at least 6 days and within 3 months more with prophylaxis

Consider other infections: Typhoid fever, hepatitis, dengue fever, avian influenza, SARS, HIV, Meningitis, Encephalittis and VHF

Urgent investigations

• Thick (find it) and thin (typify it) and rapid antigen test ( less sensitive for non falciparum, no info about parasite count, maturity or mixed species. Use in adjunct with microscopy)

• FBC: Thrombocytopenia, U&Es, LFT and

GLUCOSE

• BCM for typhoid and other bacteriemia

• Urine dipstick for haemoglobinuria and culture. Stool culture if diarrhoea

• CXR to r/o CAP

La

Laboratory diagnostic approach Diagnostic Approach

↑WBC with neutrophils ↓ WBC with neutrophils ↓ WBC with lymphocytes

Pneumonia UTILeptospirosisBrucella

TyphoidOther Salmonella

ViralRickettsial

FBC

Eosinophils: helminth, drugs. Unlikely bacterial

Very High High bili + Mod trans + Renal disfunction

Viral hepatitis Yellow feverToxin

Leptospirosis

LFTs

Falciparum Malaria or mixed infection

Admit all cases and assess severity

Complicated Malaria

Treatment

Enteric Fever(Typhoid and Paratyphoid))

• Commonest serious tropical disease from Asia

• Distribution: worldwide in developing countries

• Asia and south east Asia

>100 cases per 100.000 person per year

77% in person visiting friends and family

• Most cases occur 7 – 18 days after exposure

range 3-60 days

Clinical Presentation of Enteric Fever

Fever is almost invariable Relative bradycardia only first week

Clinical presentation of Enteric Fever

• Constipation more common than diarrhoea

initial loose stools fairly common

• Maybe evanescent rash: “Rose spots”

InvestigationsFirst 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

Complications

• Incidence: 10-15%

illness >2 weeks

• GI Bleed

• Intestinal perforation

• Typhoid encephalopathy

Vaccination provides incomplete protection

Treatment• Unstable treat empirically pending BCM

• First choice: Ceftriaxone 2g iv

• 70% of isolated S typhi and paratyphi imported into Uk are resistant to Cipro

• In patients returning from Africa resistance 4%

• If resistance to Cipro, Azitromycin

• NOTE: fever take some time to respond regardless of antibiotic use failure to defervesce is not a reason to change antibiotics if sensitive

Rickettsia: Common infection in travellers to games parks in southern Africa

RicketssiasRickettsia Africae Conorii Typhi Orientia

Tsusugamuyi

African tickbite fever

Mediterranean spotted fever fever

Murine typhus Scrub typhus from Asia

Transission Catle ticks Dog tick Rat fleas Mites

Distribution Sub-saharan African and safari park in southern Africa Eastern Caribean

Mediterranean and Caspian Litoral, Middle East , Indian subcontinent and Africa

Tropical and subtropical areas in port cities where the rodent population is dense

Rural South Asia (Laos)South East AsiaWestern pacificInfrequently report by travellers

Complications Fatal 32% Fatal 2% If untreated:Pneumonitis, CID,ARF and Meningoencephalitis

Common presentation• Incubation: 5-7 days (up to 10 days)

• Non specific fever, head ache , mialgia, inoculation echar/rash and lymphadenitis

• Consider other causes of fever and skin lesions wich resembles echar:

Antrax

African Trypanosomiasis (chancre at site of tsetse fly bite)

R Africae: multiple

R Conorii: single

R Typhi

Investigations• Treatment should be started on suspicion :

- illness onset within 10 days

- exposure to tick in game park

- fever and headache with or without rash

• Doxycyxline 100 mg bd for 7 days or 48 hs after fever defervescence

• Confimation IFA paired initial and convalescence –phase serum sample

• If wider differential is considered: Cipro or Azithromycin

Arbovirus infection

• Commonest arboviral infection in returning travellers to the UK are Dengue and Chikungunya

• Incubation: 4 – 8 days (range 3-14)

• Distribution: Asia and south America

• Repoted >100 countries and annual global incidence 50-100 million per year

• Transmission: Aedes aegypty

Clinical presentation• Mild febrile illness

Headache- retro-orbital pain

Myalgia - arthralgia (> back pain)

Rash 1st erythrodermic

2nd petechial

Bleeding gums, epistaxis and GI bleed

Rarely hepatitis, myocarditis, encephalities

and neuropathies

Convalescence desquamation and post viral fatigue

Dengue

2 days later

Dengue diagnosis and treatment

• Positive PCR or if symptoms> 5-7 days +IgM ELISA

• Retrospective > 4 fold ↑ Ig G by haemoaglutination inhibition test

• UK reference laboratory services: HPA Special Pathogens reference Unit, Poton Down

• Treatment identify those patients at high risk of shock with daily FBC and platelets.

Acute Schistosomiasis

• Katayama fever

• Incubation: 4-6 weeks ( range 3-10 weeks)

• Distribution: Africa (Asia- South America)

• Transmission: Swimming in lakes or rivers

Cercariae release from snails penetrates intact skin

Clinical presentation

• Non specific signs and symptoms (? immune complex phenomenon)

fever myalgia arthralgia

lethargy cough/wheeze headache

rash ↑Liver/spleen diarrhoea

• Investigations:

eosinophilia

egg urine-stools

minority serology + seroconversion

0-6 months)

Treatment• Diagnosis:

Fresh water exposure 4-8 weeks previously

Fever-Urticarial rash-Eosinophilia

• Treatment empiric!!!!

• Praziquantel

2 doses 20 mg/kg, 4-6 hs apart (Mature Schistosomes)

Repeat after 3 months ( Immature schistosomes)

• Short course of Steroids may alleviate acute symptoms

Leptospirosis

• Distribution: Worldwide including UK

(> tropical and subtropical regions)

• Risk: exposure to fresh surface water, rodents (infected urine)

sports events

river rafting

rescue efforts after flooding

Leptospirosis clinical presentation

• Incubation : 7 – 12 days (range 2-30 days)

• Initial phase: “flu like symptoms” lasting 4-7 days

• Immune phase: “Weil’s disease”

1-3 days later

fever, myalgia (calves)

haepatorrenal syndrome

haemorrhages

Conjunctiva suffusions suggestive

Other manifestations

• GI: V-D, loss appetite, jaundice and hepatomegaly, liver failure, pancreatitis and GI bleed

• Respiratory: Cough + SOB

• Meningitis

• ARF

• Myocarditis

• Haemorrages – may confuse DHF

Investigations

• Urinalysis proteinuria/haematuria

• FBC PMN leucocytosis

Thrombocytopenia

Anaemia

• Clotting normal (capillary fragility)

• LFT high bili + mildly raised ALT

• U&Es ARF

• Serology IgM titre > 1:320 (early infection)

> 10 days after symptoms send for IgM ELISA+ Microscopic agglutination MAT to confirm diagnosis

Treatment

• Upon suspicion

• Penicillin and tetracycline antibiotics during bacteraemia phase

• Un well patients and Weil’s disease need renal and liver support

• Severe diseases is probably immunologically

mediated ( ? Benefit from antibiotics)

Amoebic Liver Abscess

• Incubation: 8-20 weeks ( up to a year)

• Distribution : Worldwide > developing countries

• Presentation: 67-98% Fever

72-95% Abdominal pain

43-93% Haepatomegaly

20% PMH dysentery

10% diarrhoea on diagnosis

Investigations• FBC neutrophil leucocytosis > 10 X 10 6 L

• LFT dearranged ↑↑ Alk Pho

• CRP/ESR raised

• Indirect haemagglutination >90% sensitivity

• Stoolsnegative

• CxR Raised hemi-diaphragm

• USS DD piogenic abscess (percutanous aspiration) R/O Hydatidic disease first!

Amoebic Liver abscess

Treatment• Start empiric treatment in patients with suggestive

history, epidemiology and imaging

• Metronidazole 500 mg tds orally for 7-10 days ( Cure in 90%)

• Tinidazole 2 g daily for 3 days (less nauseas)

• Follow treatment with 10 days luminal amoebicide to reduce relapse.

• Furoate 500 mg tds or Paromomycin 30 mg/kg per day in 3 divided doses

Brucellocis

• Incubation: 2-4 weeks (up to 6 months)

• Distribution: world-wide ( Middle East, URRS, Balkan Peninsula and Mediterranean basin)

• Transmission: infected unpasteurised milk products. Farmers, vets with contact infected parts.

Clinical presentation

• Fever Commonest presentation

acute with rigors or

chronic low grade relapsing

• Lymphadenopathy

• Hepatosplenomegaly

Complications:

• Osteoarticular disease

OA: knees, hips, ankles and wrists

Sacroillitis lumbar spine

Other complications

• Epididymo-orchitis

• Septic abortions

• Neurological: meningitis encephalitis brain abcess

• Endocarditis: Aortic valve and requires early surgery

Investigations and treatment

• LFT: mild transaminitis

• FBC: pancytopenia

• Bone marrow: gold standard

• BCM: sensitivity 15-70% (prolong cultures up to 4 weeks)

Note: Q Fever, rarer, similar from same area

Serology is key diagnosis!!

• Treatment: Doxycycline and Rifampicin 6-8 weeks + amynoglucosides 2 weeks

• Relapse 10 %

HIV

• Prevalence in tropical countries is high 1/3 sexually active population and not restricted to high-risk groups

• 5-51% travellers take part in casual sex while abroad

• HIV seroconversion and syphilis can present as febrile illness

Hepatitis

• Incubation: A 15-50 days

B 60-110 days

E 14-70 days

• Transmission A-E faecal-oral (water, food:shellfish and direct contact)

B sex-blood

Diagnosis IgM

Traetment Supportive

Fever an respiratory symptoms• Upper respiratory tract infection: viral, St.Pneumonia, H

Influenza, Grup A steptoccoi

Diphteria in traveller returning from URRS, India, South East Asia and South America

• Lower respiratory tract infections:

HIV related PCP

Bird flu

TB (prolonged visits to families and friends) Histoplasmosis/ Coccidioidomycosis risk activities with dust and bats in caves in America

Initial treatment for “bird flu”

• Isolate

Respiratory isolation ideally negative pressure

• Samples NPA & nasal swab PCR

• Inform

Local: ICT/Virology/ID

Regional: HPA/CCDC

• Treat: Oseltamivir/Zanamavir

Fever and Neurological Symptoms• 15 per 1000 ill returned travellers

• Most common: Malaria and meningitis

• Encephalopathy: P falciparum,typhoid and HIV seroconversion

• Encephalitis with or without fever

Common causes in UK +

Arboviruses Brucellosis

Rabies Rickettsias

African trypanosomiasis

Discussion with virologist or reference laboratory

Key points

• Think of the 5 Ws

• Risk factors for disease

• Don’t miss…

– HIV (risk group)

– TB (risk group)

– Malaria (knowledge of travel)

– Enteric fever (knowledge of travel)