Approach to the Febrile Traveler PDF

Approach to Fever in a Returning Traveler Joanna Joyce MD FRCPC DTM&H Memorial University  Objectives Understand the role of the local physician in cases of fever in returning traveler Appreciate the key elements of the history and physical examin...

Approach to Fever in a Returning Traveler Joanna Joyce MD FRCPC DTM&H Memorial University  Objectives Understand the role of the local physician in cases of fever in returning traveler Appreciate the key elements of the history and physical examination in returning travelers Recognized lab studies indicated in ill returning travelers Recognize some common clinical syndromes Recognize some common incubation periods  Case 43 year old female, presents to emergency department with fever and muscle pain for 4 days. She recently returned from a trip to India where she visited family while attending her sister’s wedding.  General Approach Routine history Differential diagnoses Focused travel history Laboratory confirmation Physical findings Management decisions  Before you Start Is the patient stable? Does the patient require contact precautions or isolation? Diarrhea? Respiratory symptoms? Has the patient been in a country endemic for viral hemorrhagic fever? Have the symptoms started within 21 days of travel to that country? Rash? BMJ 2018;360:j5773  Routine History Fever pattern FULL review of systems Consider non-travel related infections Consider non-infectious causes of fever (thromboembolism, malignancy, autoimmune disease) Past medical history, medications Chronic medical conditions, immunosuppressing conditions (asplenia, HIV, hypogammaglobulinemia etc.) Immunosuppressive drugs Previous travel related illnesses Mandell, Douglas and Bennett. Principles and Practices of Infectious Diseases  Focused Travel History Itinerary Timeline Purpose of travel Prophylactic measures Mandell, Douglas and Bennett. Principles and Practices of Infectious Diseases  Travel Regions and Timeline Detailed travel itinerary Every area travelled, including transits Mode of travel (plane, ship, train etc) Timeline of travel Time spent in each area Helps narrow differential diagnoses Review travel over last 6 months (at least) Mandell, Douglas and Bennett. Principles and Practices of Infectious Diseases  Travel History: timeline ↑ length of trip = ↑ risk of travel related illness Think of incubation periods Mandell, Douglas and Bennett. Principles and Practices of Infectious Diseases  Purpose of Travel Missionary/volunteer Sex tourism Medical tourism Education Business Visiting friends and relatives Mandell, Douglas and Bennett. Principles and Practices of Infectious Diseases  Prophylactic Measures Pre-travel During travel Immunization Appropriate clothing Routine Insecticides (DEET, Picaridin, OLE, IR3535) Travel related Vigilant for tick bites Bed nets Chemo-prophylaxis Clean drinking water Anti-malarial pills Avoidance pf undercooked food/ unhygienic eating areas Handwashing  Exposures Individual exposures Type of accommodations Insect precautions taken (such as repellent, bed nets) Source of drinking water Ingestion of raw meat or seafood or unpasteurized dairy products Insect or arthropod bites Freshwater exposure (such as swimming, rafting) Animal bites and scratches Body fluid exposure (such as tattoos, sexual activity) Medical care while overseas (such as injections, transfusions Exposures Associated Infectious Syndromes Street food Enteric fever, travellers diarrhea, Local water Undercooked meat Brucellosis, Trichinosis, toxoplasmosis Unpasteurized dairy Arthropod bites Malaria, dengue, chikungunya, rickettsiosis, African trypanosomiasis Blood and body fluid Human immunodeficiency virus [HIV], HBV, hepatitis C virus [HCV], herpes exposures simplex virus [HSV], syphilis, gonorrhea (gonococcus) / Chlamydia trachomatis [GC/CT]) Fresh water activities schistosomiasis, leptospirosis Animal exposures Q-fever, brucellosis, tularemia, anthrax, rabies, Crimean-Congo hemorrhagic fever Safari Rickettsiosis, African trypanosomiasis CATMAT Statement: International traveller assessment  Physical Exam Usually fever is not accompanied by tell-tale clues Commonly associated symptoms are present in several travel- related infectious syndromes Head-to-toe exam Remember to look at mucous membranes, skin and lymph nodes  Physical Exam Vital signs: Degree of fever, pulse-fever-dissociation, blood pressure Screen for hemodynamic stability Eyes Jaundice Conjunctivitis All other systems : Ears, sinuses, cardiac, respiratory, abdominal, lymph nodes, neurological Skin and Mucous Membranes Skin and Mucous Membranes -2 BMJ 2018;360:j5773 Differential Diagnoses Put data together to form a list of differential diagnoses Region of travel, exposures, physical exam  Resources CDC yellowbook https://wwwnc.cdc.gov/travel/yellowbook/2018/table-of-contents WHO https://www.who.int/topics/infectious_diseases/en/ https://www.who.int/csr/resources/maps/en/ Promed https://www.promedmail.org/ CDC travel notices https://wwwnc.cdc.gov/travel/notices Top Diagnoses in Febrile Travelers  Malaria Parasitic disease Plasmodium sp. Most severe disease from Plasmodium falciparum Spread by Anopheles mosquito Night-biting mosquitoes Untreated infection is often fatal  Elevated transaminases Abnormal structure of blood cells: Hemolysis, anemia Splenomegaly Thrombocytopenia Release of pro-inflammatory cytokines Cyclic fever, rigors, headache Tissue hypoxia, hypoglycemia Vascular and endothelial damage https://www.cdc.gov/dpdx/malaria/index.html CLINICAL MICROBIOLOGY REVIEWS,0893-8512.July 2000, p. 439–450  Diagnosis Thick and thin smears for malaria Antigen test PCR Image source: microbeonline.com Image source: cdc.gov Image source: malariasite.com https://www.cdc.gov/dpdx/malaria/index.html  Management Screen for features of severe malaria Associated with higher mortality Requires admission to ICU IV anti-malarial drugs Choice of oral anti-malarial treatment will depend on: Species of malaria Malaria species with hypnozoite stage require additional treatment Region of travel and local resistance pattern CATMAT Guidelines CDC Recommendations Questions about Malaria? Top Diagnoses in Febrile Travelers  Travelers Diarrhea Incidence 10-40%. Risk varies by region Highest risk in South/Southeast Asia, Africa, South/Central America, May be secondary to bacteria, viruses or parasites Bacteria Viruses Parasites Enterotoxigenic Rotaviruses Giardia lamblia Escherichia coli Norovirus Cyclospora cayetensis Enteroaggregative E. Adenovirus Cryptosporidium coli parvum Campylobacter jejuni Cystisospora belli Salmonella sp. Entamoeba histolytics Shigella sp. Clostriodes difficile Vibrio sp.  Prevention Food Prophylaxis Fully cooked Dukoral Avoid salads and fresh vege Bismuth subsalicylate Fruits that can be peeled Antibiotic prophylaxis not Pasteurized dairy recommended unless patient is high risk of complications for diarrhea Fluids Bottled drinks Avoid ice  Treatment Antimicrobial therapy not usually indicated. Indications for treatment based on severity of diarrhea Mild (acute): Loperamide Diarrhea that is tolerable Bismuth subsalicylate not distressing, Hydration and supportive care does not interfere with planned activities. Moderate (acute) Loperamide Diarrhea that is distressing +/- oral antibiotics interferes with planned activities. Severe (acute) Antibiotics Diarrhea that is incapacitating Symptomatic management completely prevents planned activities; all dysentery cdc.gov Enteric fever (Typhoid Fever) Bacterial infection caused by Salmonella enterica serotype Typhi or Paratyphi Fecal-oral transmission Ingested  GI tract and liver bacteremia and dissemination (bone marrow, gallbladder,spleen, peyers patches in terminal ileum) Enteric Fever – Clinical Features Initially asymptomatic for 7- Blanching pink/red rash 14 days Relative bradycardia Fever Abdominal tenderness Fatigue Hepato-splenomegaly Diarrhea / constipation Diagnosis and Management Blood cultures Based on region of travel and resistance rates Culture of bone marrow Stool culture Widal test (not a great test) General labs Leukopenia, elevated liver enzymes, anemia European Centre for Disease Prevention and Control Top Diagnoses in Febrile Travelers Dengue Fever 4 strains Infection from one strain confers immunity to that strain Subsequent infection from another strain is a risk factor for a more severe infection Incubation period (7-10 days) Fever, bone and joint pain, vomiting, abdominal pain, muscle pain Petechiae, rash Comprehensive Review of Infectious Diseases Okay, So Back To The Case 43 year old female, presents to emergency department with fever and muscle pain for 4 days. She recently returned from a trip to India where she visited family while attending her sister’s wedding. Review of systems: No other symptoms. No gastrointestinal, genitourinary, or respiratory symptoms  Investigations (for all travelers returning with a fever) Basic work-up Complete blood count Liver enzymes Creatinine Electrolytes If travel to malaria endemic country Malaria smears (+/- antigen test) at least 3 times over 24-48 hours Blood cultures Urinalysis  Investigations Other things to add to work-up if appropriate: Chest x-ray Nasopharyngeal swab Stool for ova and parasites Stool for culture (gastroplex here in Newfoundland) Serology (Dengue, chikungunya, etc) If there is supporting epidemiology, timeline and symptoms  Management Always consider involving Infectious Diseases Malaria requires immediate treatment If malaria smears are negative, watch patient closely (re-assess after 24-48 hours) If not improving, and no diagnoses achieved (tests negative or pending) Consider treating empirically for enteric fever and/or rickettsioses Questions?