Fever in the Returned Traveler Capt Joshua Latham D.O. Family Medicine (PGY-3) 19 March 08 1000 - 1045 Objectives Identify the most common causes for fever in the returning traveler Understand how timing and geographical history assist in establishing a differential Recognize some physical exam clues to augment the history Improve your knowledge base of a few important infectious causes for fever IT TAKES 43 MUSCLES TO FROWN AND 17 TO SMILE, BUT IT DOESN’T TAKE ANY TO JUST SIT THERE WITH A DUMB LOOK ON YOUR FACE Resources CDC - www.cdc.gov - http://wwwn.cdc.gov/travel/contentYellowBook.aspx Armed Forces Medical Intelligence Center - www.afmic.detrick.army.mil GIDEON - www.gideononline.com AAFP - www.aafp.org Illness among travelers to developing world 22-64% self report health complaints 8% seek medical care per year… 50 million travelers = 4 million visits GeoSentinel: Clinical Infectious Disease 2007 Diagnoses among returning travelers Acute Diarrhea Systemic 20% Derm d/o Febrile Illness 15% 21% Chronic Diarrhea other 10% 34% (Freedman et al. NEJM 2006 – GeoSentinel Data) 4 major categories comprise 2/3 illnesses Fever (Wilson et al. Clin Inf Dis 2007 – GeoSentinel Data) CC in 28% of over 24,000 pts Broken down by syndromes… 35% systemic febrile illness 15% febrile diarrheal illness 14% respiratory illness 22% undifferentiated Fever – etiology (Wilson et al. Clin Inf Dis 2007 – GeoSentinel Data) Overall #1 overall … MALARIA Systemic febrile illness - Malaria - Dengue - Enteric Fever - Rickettsial diseases Evaluation History, History, History PE Supporting lab work Expert consultation when indicated Identify signs requiring urgent intervention A Broad Differential Fever unrelated to travel - “common things being common” Travel related non-infectious - thrombophlebitis, PE, drug fever Infectious considerations - en-route exposures - geographic considerations - in-country exposures Essential History (5 W’s) Who Where* What When* Why WHO The patient… Age/sex, PMH, Medications - may affect M&M Vaccinations/hx of infections - various efficacy of vaccinations - susceptibility WHO The patient (cont)… preparations for travel - pre-travel clinic - prophylaxis and protections used Other travelers … similar exposures? - foods, events, locations symptomatic? - same illness, different sx, timeframe NEVER UNDERESTIMATE THE POWER OF STUPID PEOPLE IN LARGE GROUPS WHERE Geographic and specific destinations - narrows differential Accommodations - living quarters - water supply Travel plans - type of transport - layovers/intermediate stops Geographic Considerations (Freedman et al. NEJM 2006 – GeoSentinel Data) Etiology of Systemic Febrile Illness per Region 700 600 Malaria 500 Dengue # of cases/1000 400 Mono (EBV or CMV) 300 Rickettsial Infection 200 Typhoid/Paratyphoid 100 0 All Sub- Southeast South South Central Caribbean Regions Saharan Asia Central America America Africa Asia Geographic Considerations (Freedman et al. NEJM 2006 – GeoSentinel Data) Sub-Saharan Africa - prioritize malaria - include rickettsial infections in DDx Southeast Asia - think dengue, then malaria - remember possible mefloquine resistance South Central Asia - Suspect typhoid and paratyphoid Geographic Considerations (Freedman et al. NEJM 2006 – GeoSentinel Data) Etiology of Systemic Febrile Illness per Region 700 600 Malaria 500 Dengue # of cases/1000 400 Mono (EBV or CMV) 300 Rickettsial Infection 200 Typhoid/Paratyphoid 100 0 All Sub- Southeast South South Central Caribbean Regions Saharan Asia Central America America Africa Asia Geographic Considerations (Freedman et al. NEJM 2006 – GeoSentinel Data) Central and South America - malaria and dengue most prominent - cutaneous leishmaniasis and myiasis (non- febrile) - bartonellosis (Andes mountains) Caribbean - dengue, then malaria - cutaneous larval migrans (non-febrile) Accommodations and Exposures Quarters - urban vs rural - availability of protection from creatures Water - contaminated drinking sources - bathing water Infections acquired during Travel Transmission during travel can occur - Influenza, TB, SARS Risk factors include - duration of exposure - proximity - severity of source pt - ventilation system Consider all areas visited WHAT Exposures Foods Activities Encountered critters Exposures Water Fresh - lepto, schisto, hep A, melioidosis, enteric bacteria Salt Water - vibrio, hep A Animals Cattle, Sheep - brucella, coxiella, anthrax, tularemia Rodents - hantavirus, lassa fever, typhus Cats/Dogs - rabies, pasteurella, bartonella, toxo Humans Sexual - STI’s, HIV, hepatitis Non-sexual - TB, measles, diphtheria, varicella Exposures Foods Raw stuff - tape worms (meats) - ascariasis, liver flukes (vegetables) - lung/intestinal flukes (fish, crustaceans) Unpasteurized dairy - brucella, coxiella, listeria Insects Mosquitoes, flies, sand flies - malaria/dengue, yellow fever, arboviruses, filariasis, leishmaniasis, Oroya fever, babesiosis Ticks, fleas, mites, lice - rickettsial diseases, typhus, relapsing fevers, plague IT COULD BE THAT THE PURPOSE OF YOUR LIFE IS ONLY TO SERVE AS A WARNING TO OTHERS WHEN Dates of travel - seasons/climate Duration of stay - period of exposure Onset of symptoms -incubation periods and clinical course Timing: Length of Stay Brief exposure - arthropod borne illnesses and ingestion of contaminated foods Prolonged exposure - filarial and some helminthic infections Incubation Period < 2 weeks Malaria Meningococcemia Dengue Viral encephalitis Rickettsial Infections Hemorrhagic fevers Leptospirosis Tularemia Typhoid Relapsing fever Paratyphoid Polio Brucellosis Angiostrongylus Melioidosis Rabies African Acute HIV Trypanosomiasis (Suh, Kozarsky, Keystone. Med Clin North Am 1999) Incubation Period 2-8 weeks Malaria Hemorrhagic fevers Leptospirosis Liver abscess Typhoid Toxoplasmosis Paratyphoid Hepatitis A & E Brucellosis Schistosomiasis Melioidosis Q-fever Trypanosomiasis Oroya fever (Suh, Kozarsky, Keystone. Med Clin North Am 1999) Incubation Period >2 months Malaria Visceral Melioidosis Leishmaniasis Liver abscess Tuberculosis Rabies Lymphatic filariasis Hepatitis B Fascioliasis (Suh, Kozarsky, Keystone. Med Clin North Am 1999) Highlights of Timing >60% of dengue seen < 1 wk >90% P. falciparum malaria <1 month >50% P. vivax/ovale malaria >1 month >1/3 hepatitis A >6 wks Most severe, life-threatening infections are apparent within 3 months WHY Reason for travel… Vacation Mission/medical work Visiting friends/relatives - less seek pretravel medical advice - greater risk for vaccine-preventable illnesses - more likely to get fever JUST BECAUSE YOU’VE ALWAYS DONE IT THAT WAY DOESN’T MEAN IT’S NOT INCREDIBLY STUPID Take Home for History Narrow differential with thorough history Timing and Location are highest yield Visitors friends/relatives increased risk Life-threatening infections < 3 months Physical Exam Recognize signs for urgent intervention Perform thorough exam Combine your history and PE to refine the differential Indications for Urgent Intervention Respiratory Distress Hypotension/hemodynamic instability Confusion,lethargy, stiff neck, focal neurologic findings Hemorrhagic manifestations Interventions Supportive care and stabilization as indicated Consider empiric medication therapy - IV anti-malarials + broad spectrum antibiotics - oral medications to consider Malarone/Mefloquine Doxycycline FQ Continue attempts to identify etiology PE Clues VS relative bradycardia - typhoid, rickettsial dz Skin maculopapular rash - dengue, lepto, typhus eschar - rickettsial dz rose spots - typhoid petechiae - meningococcemia, VHF, dengue Eschar Rose Spots PE Clues ENT conjunctiva - leptospirosis, VHF injected common infxns - AOM, sinusitis, strep pharyngitis Abdomen splenomegaly - malaria, mono, typhoid, brucellosis, lepto PE Clues Lymphadenopathy localized - TB, MAC, plague, typhus, trypanosomiasis, filariasis generalized - brucellosis, lepto, TB, melioidosis, dengue, leish (visceral) PE Clues Pulmonary URI/LRI - influenza, legionella parenchymal involvement - TB, VHF, helminths, protozoa Neurological AMS - meningococcal, malaria, entero and arboviruses, typhoid, rickettsial, lepto eosinophilic meningitis - angiostrongylus Routine Labs CBC with differential Liver enzymes - AST, ALT, AP Liver function tests - coags, alb, platelets Blood cultures Blood smears Thick and thin blood smears Q 12-24 hrs x 72 hrs Other tests if indicated… Stool cultures, WBC’s, O/P’s CXR or other imaging Lumbar puncture Biopsies Serologies Evaluation Summary Start broad on the differential Narrow differential using the 5 W’s Identify when urgent intervention is needed Utilize PE to strengthen suspicion Augment H/P with appropriate lab tests NO MATTER HOW GREAT AND DESTRUCTIVE YOUR PROBLEMS MAY SEEM NOW, REMEMBER, YOU’VE PROBABLY ONLY SEEN THE TIP OF THEM Malaria Protozoa: Plasmodium (4 species) 300 – 800 million new infections yearly 1-3 million deaths per year Incubation typically 7-30 days Systemic febrile illness Malaria Diff dx #1,2,3 in traveler with fever Diagnosis is made by blood smear - performed q 12-24 hrs x 72 hrs if suspected Concerning factors - altered mental status (GCS <11) - >10% parasitemia - >5% neutrophils with pigment - hypoglycemia - pulmonary edema Treatment of Malaria Treatment based on species and resistance - http ://www.cdc.gov/malaria/pdf/treatmenttable.pdf Hospitalization - falciparum malaria - severely ill - undetermined speciation Severe/cerebral malaria - ICU - parenteral therapy (quinidine, chloroquine) - no evidence of benefit from steroids* * EBM (LOE C): Prasad, Garner. Cochrane Review 1999. Dengue (Break-bone fever) flaviviruses Aedes mosquito (day biters) Incubation 3-14 days Systemic febrile illness - retro-orbital pain, backache - rash noted in 50% - hemorrhage, shock Dengue Diagnosis primarily clinical - serologies available Hemorrhagic fever - previously infected patients - mortality increases with shock Treatment is supportive - aggressive fluid hydration - blood, FFP, etc. - ASA is contraindicated - No benefit from steroids* * EBM (LOE C): Panpanich et al. Cochrane Review 2006. Enteric Fever Typhoid/Paratyphoid fever (10:1) Salmonella typhi and paratyphi Incubation 5-21 days Systemic febrile illness - constipation, abdominal pain - rose spots (30-50%) - relative bradycardia Enteric Fever Diagnosis - blood, urine cultures - bone marrow culture most sensitive Treatment - oral – cipro 500mg x 7-10 days - IV – Ceftriaxone 2g/day x 7-10 days - dexamethasone for AMS* - may treat for schistosomiasis Prevention - vaccine available (50-80% effective) * EBM (LOE C): Aberdein J. Crit Care 2006. Viral Hemorrhagic Fever Manifestations Systemic febrile illness - fever, HA, abdominal pain, sore throat, myalgias and diarrhea More suggestive of VHF - pharyngitis, conjunctivitis, rash - hemorrhage and shock Recommendations for Suspected VHF (CDC) Initial evaluation - standard precautions are acceptable Upon hospitalization - isolation - contact and droplet precautions - avoid all contact with bodily fluids Airborne precautions - advanced stages - cough, vomiting, diarrhea, or hemorrhage Recommendations for Suspected VHF (CDC) Reduce exposure - avoid percutaneous injuries - minimize lab draws - disinfect contaminated surfaces - dispose of linens properly - minimal handling of corpse Exposure - immediately wash surface/wound with soap and water - copious irrigation of mucous membranes MAY NOT BE WARRANTED AT THIS POINT What we learned… Always think malaria with fever When it comes to travel history… - Location, location, location - Timing is everything Identify need for intervention and seek additional help Fine tune the history with your PE Swift diagnosis and treatment is paramount - with ill patients, consider empiric therapy When it comes to motivational sayings… IF A PRETTY POSTER AND A CUTE SAYING ARE ALL IT TAKES TO MOTIVATE YOU, YOU PROBABLY HAVE A VERY EASY JOB. THE KIND ROBOTS WILL BE DOING SOON. References Aberdein J, Singer M. Clinical Review: A systematic review of corticosteroid use in infections. Crit Care 2006; 10:203 Bottieau E, Clerinx J, Schrooten W, et al. Etiology and outcome of fever after a stay in the tropics. Arch Intern Med 2006; 166:1642-1648 CDC. CDC Surveillance Summaries, Malaria Surveillance: United States, 2002. MMWR 2004; 53:21-24 CDC. Health Information for International Travel 2008. DHHS, Atlanta, GA CDC. Management of patients with suspected viral hemorrhagic fever. MMWR 1988; 37:1-15 CDC. Update: management of patients with suspected viral hemorrhagic fever--United States. MMWR 1995; 44:475-479 Control of Communicable Diseases Manual. David L. Heymann. Washington DC, USA: American Public Health Association, 18th (ed) 2004 Freedman DO, Weld LD, Kozrsky PE, et al. Spectrum of disease and relation to place of exposure among ill returned travelers. N Engl J Med 2006; 354:119-130 References Guarda JA, et al. 1999. Malaria Re-emergence in the Peruvian Amazon Region. Available at: http://www.cdc.gov/ncidod/eid/vol5no2/arambG.htm. Accessed on 24 Feb 2008. Huber J. 2003. Politically Correct. Available at: http://www.conservativecartoons.com/cartoon.php?toon=304. Accessed on 24 Feb 2008. Lo Re V, Gluckman SJ. Fever in the returned traveler. Am Fam Physician 2003; 68(7):1343-1350 Olsen SJ, Chang HL, Cheung TY, et al. Transmission of the severe acute respiratory syndrome on aircraft. N Engl J Med 2003; 349:2416- 2422 Panpanich R, Sornchai P, Kanjanaratanakorn K. Corticosteroids for treating dengue shock syndrome. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD003488. DOI: 10.1002/14651858.CD003488.pub2 Prasad K , Garner P. Steroids for treating cerebral malaria. Cochrane Database of Systematic Reviews 1999, Issue 3. Art. No.: CD000972. DOI: 10.1002/14651858.CD000972 Suh KN, Kozarsky PE, Keystone JS. Evaluation of fever in the returned traveler. Med Clin North Am 1999; 83:997-1017 References Schwartz E, Parise M, Kozarsky P, Cetron M. Delayed onset of malaria – implications for chemoprophylaxis in travelers. N Engl J Med 2003; 349:1510-1516 Steffen R, deBernardis C, Banos A. Travel epidemiology – a global perspective. Int J Antimicrob Agents 2003; 21:89-95 Thompson J. Role of glucocorticosteroids in the treatment of infectious diseases. Eur J Clin Microbiol Infect Dis. 1993; 12(1):S68- S72 Wilson ME, Weld LH, Boggild A, et al. Fever in returned travelers: Results from the GeoSentinel Surveillance Network. Clin Infect Dis 2007; 44:1560-1568 Wilson ME. June 2007. UpToDate. Evaluation of fever in the returning traveler. Available at: http://www.utdol.com/utd/content/topic.do?topicKey=immunize/5453& selectedTitle=1~150&source=search_result. Accesed on 6 Feb 2008. Update on Malaria in South Africa 2003. Available at: http://www.malaria.org.za/Malaria_Risk/Update/update.html. Accessed on 24 Feb 2008.
Pages to are hidden for
"Latham Fever in the Returned Traveler1 PPTminimizer"Please download to view full document