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ID 3 Common infections in the returning
traveller or migrant, Dr Anna Checkley
Speaker key
IV
AC
Interviewer
Anna Checkley
AC
Hello. My name is Anna Checkley. I’m a Consultant in Infectious Diseases at
UCLH Hospital and Hospital for Tropical Diseases. My talk today was about common
causes of fever in returning travellers.
IV
What are the common infections that returning travellers and migrants may
have?
AC
So, these can be divided into three main groups: people presenting with fever,
with diarrhoea, and with rash. Taking fever first, the commonest and most important
cause of fever in returning travellers is malaria, and I'll talk a little bit about that first.
Other causes of fever in returning travellers include typhoid, Rickettsiala infections,
including African Tick Typhus, Chikungunya and Dengue, and of course it’s also
important not to forget the recent outbreaks which have occurred, including Ebola
disease and viral haemorrhagic fevers and MERS.
So, starting with malaria: malaria is an infection which presents non-specifically,
almost always with fever, but also with diarrhoea, myalgia, headache and so on, so
it’s important to think about malaria and to screen for malaria in any patients
returning from tropical travel within the last year. Because of turnaround times and
logistics we suggest that GPs refer all patients with fever who might have a diagnosis
of malaria, to Infectious Disease Services, such as ours, to have a same-day malaria
film performed.
Following the diagnosis of malaria, if the malaria is non-severe, so if the peripheral
parasitaemia is less than 2% and if the patient has no complications, they can be
treated with oral treatment and our first line for that is Riamet and Artimesan in
combination therapy. Generally this is being done as an inpatient but there’s
increasing evidence recently that a small subset of patients may be treated safely as
outpatients.
Severe malaria with a parasitaemia of greater than 2% or with any complications, any
renal, respiratory, cerebral complications, is treated with intravenous Artesunate now
and the AQUAMAT and SEAQUAMAT trials published in 2005 and 2010
conclusively demonstrate that this is superior to quinine, the previous treatment.
One last thing to be aware of in primary care is the phenomenon of post-artesunate
haemolysis which occurs 2-4 weeks after treatment, so once the patient has been
discharged and is at home, and the degree of haemolysis is proportional to the degree
of parasitaemia initially, and we see patients with haemoglobins dropping by about
one or 2g and as a result, we routinely screen patients with a full blood count a month
after they’ve been discharged with malaria.
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So, moving on to typhoid, this is another infection that we see commonly in returning
travellers, particularly coming back from Asia and Southeast Asia, and again it
presents non-specifically so with fever, headache and myalgia; sometimes with
gastrointestinal symptoms such as diarrhoea or constipation but by no means in all
cases. It’s diagnosed generally by blood culture and is treated with third generation
cephalosporins so intravenous Ceftriaxone as an inpatient in unwell patients, and with
oral Azithromycin potentially as an outpatient in patients who are well and stable.
The global development of antibiotic resistance is particularly important in the case of
typhoid and it’s important to note that Ciprofloxacin is no longer an effective
treatment for typhoid infection with more than 50% of cases of typhoid that we see at
HTD from South Asia and Southeast Asia being resistant to Ciprofloxacin first line.
Another thing that it’s worth being aware of is that even when a patient is put on an
appropriate antibiotic therapy confirmed to be the right antibiotic with sensitivity
testing of blood culture results it takes a long time for defervescence to occur so we
would commonly discharge a patient who still had a fever but who was clearly
responding to treatment so it may well be that you would see patients in primary care
with on-going fevers, but who were well, and so long as they remain well and are on
appropriate antibiotics then that would be normal and we would expect it to take up to
about seven days for the fever to settle with a patient with typhoid infection.
IV
What should the GP bear in mind about MERS?
AC
So, you should think about MERS or Middle Eastern Respiratory Syndrome in
patients who have returned from travel to one of the endemic areas within the last 14
days, and those areas include the Middle East, all of the Middle East, and also Korea.
Patients present with a severe respiratory illness and fever, and patients who fit that
case definition should be referred immediately up to the infectious diseases registrar
on call and we will then arrange to isolate that patient on arrival to A&E and conduct
a risk assessment and then possibly go on and test the patient for MERS.
IV
How can we manage diarrhoea in returning travellers in primary care?
AC
So diarrhoea is a common problem in returning travellers and as first line
investigations in primary care, we’d suggest a basic screen, including a stool sample
sent for culture for bacterial pathogens and also for microscopy for ova cysts and
parasites, a full blood count looking for eosinophilia which might be suggestive of
helminth infections such as, for example, Strongyloides or Schistosomiasis and
considering sending Strongyloides zoology depending on the travel history and
exposure history of the patient.
Red flags which should prompt consideration of referral for investigation at, for
example, Hospital for Tropical Diseases include a patient with fever, and it’s
important to be aware that malaria can present with fever and diarrhoea, presence of
blood in the stools and any patient who is either failing to improve or is generally
unwell.
There is a mixed body of evidence as to the role of empirical treatment for travellers’
diarrhoea, and it’s probably the case that a subgroup of patients should be considered
for empirical treatment and those are the people who are at particular risk of
dehydration or progression of their illness, and that includes the elderly and immuno2
compromised patients. If you’re considering empirical treatment then first line
treatment should be either Ciprofloxacin, either a one or a three-day course or a stat
dose of Azithromycin, and the latter is useful because it’s also effective against
Campylobacter which is a common cause of travellers’ diarrhoea.
IV
What about rash?
AC
So rash is another common presentation in the returning traveller and can
indicate a number of different diagnoses, in particular common causes that we see
include Katayama fever, Rickettsia infections such as in particular Tick Typhus in
patients returning from Southern Africa and of course it’s very important to not forget
acute HIV infection which we routinely screen for in all patients who we see in our
clinics.
IV
Where can GPs find out more?
AC
So, I’d suggest you start by looking at the HTD website, which is found at
www.htd.org and if you scroll to information for doctors and scroll to the bottom of
that page you can find our malaria treatment guidelines and there were also several
presentations done at various GP education evenings which can be found under the
GP library, and subjects such as these and others can be found there. You’re also very
welcome to contact me directly on [email protected].
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