Download Fever in the returning traveler - Canadian Association of Emergency

Fever in the returning traveler
St John’s NFLD, June 2011
Rob Stenstrom MD, PhD
Rob
Stenstrom MD PhD
St Paul’s Hospital Department of Emergency Medicine University of British Columbia
University of British Columbia
Disclosure: I love to travel!
Disclosure: I love to travel!
Take home points
Take home points
1. Fever
Fever in the returning traveler is malaria until in the returning traveler is malaria until
proven otherwise
2 Spectrum of disease presentation is variable 2.
S t
f di
t ti i
i bl
depending on prior exposure and/or immunization
3 A high index of suspicion and thorough travel 3.
A high index of suspicion and thorough travel
history are essential 4. You can’t know about all of the possible diseases; A history of travel should alert you to the possibility of a travel‐related illness
Background and Epidemiology k
d d d
l
In 2007, 812 million people crossed international borders 53 million travel from developed to developing world
53 million travel from developed to developing world
Doubling in last 20 years 20‐70% report travel related illness Up to 5% will seek medical care
Up to 5% will seek medical care
Tons of diseases to consider….
•AIDS
•African Trypanosomiasis
Amebiasis
•American Trypanosomiasis (Chagas’ Disease)
•Bovine Spongiform Encephalopathy and Variant Creutzfeld‐Jakob Disease
•Cholera
•Coccidioidomycosis
•Cryptosporidiosis
•Cyclosporiasis
•Dengue Fever
•Diptheria, Tetanus and Pertussis
•Encephalitis, Japanese
•Encephalitis, Tickborne
•Filariasis, Lymphatic
•Giardiasis
•Haemophilus influenzae Type b Meningitis and Invasive Disease
•Hepatitis A
•Hepatitis B
•Hepatitis C
H
ii C
•Hepatitis E
•Histoplasmosis
•Influenza
•Legionellosis
Legionellosis
•Leishmaniasis
•Leptospirosis
•Lyme Disease
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Malaria
Measles
Meningococcal Disease
Meningococcal Disease
Mumps
Norovirus Infection
Onchocerciasis (River Blindness)
Plague
Poliomyelitis
Rabies
Rickettsial Infection
Rubella
Schistosomiasis
SARS
Sexually Transmitted Disease
Smallpox
Steptococcus pneumoniae
Traveler’s Diarrhea
Tuberculosis
Typhoid Fever
Varicella (Chickenpox)
Viral Hemorrhagic Fever
Yellow Fever
TropNetEurope and multinational Geosentinel
and multinational Geosentinel
Surveillance Database (> 250,000 visits). Most common infectious diagnoses related to travel: 1. Diarrhea (bacterial > parasitic) 2. Hepatitis A
3. Malaria
4. Dengue fever
f
5. Typhoid
Spectrum of Disease and Relation to Place of Exposure among Ill Returned
Travelers. David O. Freedman, et al. NEJM, January 2006
Rare diseases Rare
diseases are
Rare!! Ebola virus disease, Japanese encephalitis, rabies, tetanus diphtheria plague tularemia murine
tetanus, diphtheria, plague, tularemia, murine
typhus, Rift Valley fever, poliomyelitis, primary amebic meningoencephalitis, anthrax, Hantavirus bi
i
h liti
th
H t i
not reported once in over 40,000 cases of febrile returning travelers
Reasons for travel
60%
Percent
50%
40%
30%
20%
10%
0%
Vacation
VFR
Business
Other
Reason
The tterm VFR (Vi
Th
(Visiting
iti F
Friends
i d and
dR
Relatives)
l ti
)d
describes
ib
an immigrant, ethnically and racially distinct from the
majority population of the country of residence
residence, who
returns to their country of origin to visit friends or relatives
(CDC)
Common Causes of fever in the returned traveler
URTI
STI
UTI
Mono
Gastroeneteritis
VTE
The travel history
The travel history
•
•
•
•
•
•
•
•
•
•
•
Get a (good) translator!
(g
)
Where visited/rural/urban For how long
For how long
Pattern of fever/antipyretics
Immunizations prior
p y
Prophylaxis
Activities undertaken
Sexual contacts
Sexual contacts
Contact with animals
Medications (immune‐modulators)
PMH (chemo, etc) What is en/epidemic where they
What
is en/epidemic where they
were? • Pacific North West: Cryptococcus gatti: over 60 cases, 12% fatality rate; mostly completely healthy previously
• Ongoing E‐coli outbreak in Europe
• New outbreak of measles in travelers returning from u ope ost y
o
u ed c d e ; ajo
Europe mostly in non‐immunized children; Major outbreak in France – 6 deaths. Case: 42 year old male in Africa for 2 weeks
On safari in Kenya; returned 3 weeks ago
No PMhx; No specific immunizations
No PMhx; No specific immunizations Took Malaria prophylaxis
Symptoms: Fever, malaise, anorexia, nausea, abdo pain
p
• On exam: N vitals, T 37.1⁰ oral. Benign abdomen
bd
• CBC, lytes
y BUN Creatinine urine dip all N
p
•
•
•
•
Case: 42 year old male in Africa for 2 weeks
• Fluids, gravol → home
• Returns the next day jaundiced
Returns the next day jaundiced
Diagnosis??
Hepatitis A
p
Hepatitis A
p
• After infectious diarrhea most common disease in travelers seeking medical help; most common vaccine preventable • 1000 times more common than Yellow Fever
Fatality rate of 0 5‐1
Fatality rate of 0.5
1.3%; tends to be milder in children (70% 3%; tends to be milder in children (70%
asymptomatic)
• Cases of acute liver failure with Hepatitis A and (therapeutic) doses of Acetaminophen • New inactivated HAV vaccines induce protective antibodies in more than 95% of recipients and offer protection estimated to last for 10 years
• Treatment: supportive
Treatment supportive
Hepatitis A distribution
Hepatitis A distribution
Case: 51 year old male visiting Thailand
• Fever, extreme myalgias, arthralgias, rash
Dengue Fever: g
•
Aedes aegypti mosquito – day biting, common in cities
•
Short incubation: 3‐15 days
•
Flavivirus with 4 antigenically
with 4 antigenically distinct serotypes
distinct serotypes
•
Immunity specific for each serotype
•
Most common cause of fever in the returning traveler from Asia/Indian sub‐continent
from Asia/Indian sub‐continent
•
Symptoms: Fever, myalgias (breakbone fever) arthralgias, headache, rash. Can be biphasic
•
60‐70
60
70 cases per year in Canada (serologic test)
cases per year in Canada (serologic test)
•
CFR 5%
Distribution of Dengue fever and Aedes aegypti
Mosquito
Dengue Haemorrhagic fever
Dengue Haemorrhagic
•
Uncommon in travelers
Uncommon in travelers •
Frequently fatal
•
Associated with prior Dengue infection with another DF serotype
DF serotype Case: 32 year old Female
Case: 32 year old Female
Moved here from India 8 years ago
Moved
here from India 8 years ago
Returned from a visit home to India 12 days ago
H F
Hx: Fever, myalgias, dark urine
l i d k i
Ex: Unwell
VS: Temp: 40oC
BP: 90/55
BP: 90/55
Pulse: 142
R
Resp: 22, O
22 O2 sat. 97% t 97%
21
Case: Case:
• Labs:
Labs: CBC: Hb 125, Platelets 110, WBC 3.1 CBC: Hb 125, Platelets 110, WBC 3.1
with lymphopenia; Lytes BUN creatinine N
T
Transaminases, LDH doubled; Lactate 1.8 (N)
i
LDH d bl d L t t 1 8 (N)
Bili 67; Blood smear: slight hemolysis
;
g
y
• Physical exam: Scleral
h
l
l l icterus, splenomegaly
l
l
Lab findings in disease states
Lab findings in disease states Finding
Finding Disease
Hemoconcentration
Dengue
Thrombocytopenia, leukopenia
Malaria, Dengue
↑ transaminases
Hemolysis (
↑ LDH, Bili)
Hypoglycemia E i
Eosinophilia
hili
Malaria, Dengue, Typhoid Malaria, Hepatitis, yellow Malaria
Hepatitis yellow
fever
Parasitic infection; drug P
iti i f ti
d
reaction
Malaria
• Female anopheles mosquito
• Incubation corresponds with liver stage of malaria parasite
g
p
Incubation
–P. falciparum
7 Days‐8 weeks
– P. vivax
P vivax
– P. ovale
– P. malariae
14 Days ‐
14
Days 1 year
1 year
14 Days ‐ 1 year
30 Days ‐ 1 year
Semi‐immune people such as immigrants and visitors from endemic
areas and those taking chemoprophylaxis may have delayed onset
of illness and mild symptoms.
MALARIA
MALARIA
• Risk
Risk of traveler acquiring malaria 200
of traveler acquiring malaria 200‐
500/100,000
• 60‐70% of reported cases = falciparum
60 70% of reported cases = falciparum (most (most
from sub‐Saharan Africa)
• 15% by P. vivax
15% by P vivax (the majority from the Indian (the majority from the Indian
subcontinent) • 9% by P. ovale
9% b P
l Case fatality rate = 3‐5%
C
f li
3 5%
• 500 cases year in Canada
• 3‐5 deaths per year (Canada)
• Now > 100 cases worldwide of Now > 100 cases worldwide of “airport
airport malaria
malaria”
MALARIA
• IIn any given year, nearly 10% of the global population will suffer i
l 10% f th l b l
l ti
ill ff
from malaria
• Risks for mortality include:
Risks for mortality include:
– traveler's delay in seeking medical attention for fevers
– inadequate access to parenteral
inadequate access to parenteral therapy for severe malaria in therapy for severe malaria in
Canada
–delayed or inadequate care by d l d i d
b
Canadian physicians and hospitals
Canadian physicians and hospitals.
Investigations
CBC‐diff
Lytes, BUN, creatinine, gl‐
l
LFTs, transaminases
Thick and thin smear for malaria repeated (if neg q 8‐
12h x 3
12h x 3
• Blood/urine/stool/culture • ELISA for antibody detection, ELISA for antibody detection
as indicated
• Radiography
•
•
•
•
DEET: N N Diethyl meta toluamide
DEET: N,N‐Diethyl‐meta‐toluamide
One application of 25% lasts up to 5 hours
Not to face
Not to face
Not in kids < 1 year old N t on pets or St Paul’s staff who are prone to Not
t
St P l’ t ff h
t
attempt licking themselves
Other bad actors:
Other bad actors: Traveler'ss Diarrhea
Traveler
Diarrhea
•
•
•
•
31
Common!
Majority bacterial
Majority bacterial
Loperamide and antibiotics good
See Campana’s (better) talk
HIV and other STIs
HIV, and other STIs
Rickettsial diseases
Rocky Mountain spotted fever, Q fever, etc
Q fever, etc
Short incubation period; 2‐8 days
Headache fever myalgias
Headache, fever myalgias
Tick bite hx absent in 30%
Yellow fever
Yellow fever
• Aedes mosquito; flavivirus
• Vaccine near 100% efficacy (10 years)
• Treatment supportive; 5% mortality
Treatment supportive; 5% mortality
Typhoid fever
Typhoid fever
• Salmonella Typhi
• Fecal‐oral transmission
• Fever, H/A, abdo pain, constipation; less frequently, di h
diarrhea
• 3‐4 weeks; Mortality 12‐30% if untreated
• Blood cultures + in 60‐70% of cases Blood cultures + in 60 70% of cases
• Treatment is fluoroquinolone or 3rd generation cephalosporin
Cholera
• Sudden Onset
– Incubation 1 –
Incubation 1 5 days
5 days
– Therefore RARE in the returned traveler
• Vaccine
– Reduces rate of infection by no more than 50%
– effective for no more than 3‐6 months
ff ti f
th 3 6
th
• Raw Shellfish: No es Bueno!
– USA: sporadic cases from the Gulf of Mexico
USA
di
f
th G lf f M i
– Sporadic cases of travelers bringing contaminated seafood home
West Nile Virus:Confirmed
West
Nile Virus:Confirmed cases in cases in
Canada – 2008 ▀
▀
Travel related
Positive 37
Useful websites:
• http://www.CDC.gov/ p
g
• http://www.who
• http://www.malariajournal.com/content/8/
h //
l i j
l
/
/8/
1/202/comments
• http://medical‐
dictionary thefreedictionary com/Cerebral+
dictionary.thefreedictionary.com/Cerebral+
malaria
Take home points
Take home points
1 FFever in the returning traveler is malaria
1.
i th
t i t
l i
l i
until proven otherwise
2. Spectrum of disease presentation is variable depending on prior exposure and/or immunization
3. A high index of suspicion and thorough travel A high index of suspicion and thorough travel
history are essential 4 You can
4.
You can’tt know about all of the possible know about all of the possible
diseases; A history of travel should alert you to the possibility of a travel‐related illness
to the possibility of a travel‐related illness
Thanks!