Latham Fever in the Returned Traveler1 PPTminimizer by Z6Y96WL

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									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
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   Control of Communicable Diseases Manual. David L. Heymann.
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   Freedman DO, Weld LD, Kozrsky PE, et al. Spectrum of disease and
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    Med 2006; 354:119-130
                       References
   Guarda JA, et al. 1999. Malaria Re-emergence in the Peruvian
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                       References
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   Wilson ME, Weld LH, Boggild A, et al. Fever in returned travelers:
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   Wilson ME. June 2007. UpToDate. Evaluation of fever in the returning
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    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
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