* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download The Returning Traveller
Orthohantavirus wikipedia , lookup
Poliomyelitis eradication wikipedia , lookup
Plasmodium falciparum wikipedia , lookup
Trichinosis wikipedia , lookup
Marburg virus disease wikipedia , lookup
Gastroenteritis wikipedia , lookup
Traveler's diarrhea wikipedia , lookup
Yellow fever wikipedia , lookup
1793 Philadelphia yellow fever epidemic wikipedia , lookup
Eradication of infectious diseases wikipedia , lookup
Middle East respiratory syndrome wikipedia , lookup
Rocky Mountain spotted fever wikipedia , lookup
Coccidioidomycosis wikipedia , lookup
Schistosomiasis wikipedia , lookup
Yellow fever in Buenos Aires wikipedia , lookup
Leptospirosis wikipedia , lookup
Hepatitis B wikipedia , lookup
The Returning Traveller Dr Catherine Cosgrove MBBS MRCP PhD DipHIV Senior Clinical Lecturer and Honorary Consultant in Infectious Diseases Objectives • • • • Travel history Short Quiz Common case studies Summary Travel History Over 61 million trips abroad Travel History • Place; cities,towns,rural • Exact dates • Accommodation; AC/ nets • Food, water, insect exposure • Contact with sick / dead people • Family history • TB contacts • • • • Sexual history Animal exposure Purpose of visit Itinerary – Fresh water exposure – Caving • Malaria prophylaxis • Vaccine history Quick Quiz • Rate of diarrhoeal illness in travellers (Uk to low income countries) • No of documented GI infections after travel 2004-2008 • Top diagnosis (organism) • Top destination • Highest risk destination – – – – – Salmonella Campylobacter Shigella Giardia Cryptosporidium • % cases with no documented isolate Quick Quiz • Rate of diarrhoeal illness in travellers (Uk to low income countries)- 60% • No of documented GI infections after travel 2004-200824000 • Top diagnosis (organism)- Salmonella • Top destination- Spain • Highest risk destination – – – – – Salmonella- Egypt Campylobacter- Spain Shigella- India Giardia- India Cryptosporidium- Spain • % cases with no documented isolate- 40% Travellers Diarrhoea Map designed and produced by the Travel and Migrant Health Section, HPA. The risk zones have been defined based on published TD studies [2, 8-11] http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1287146380314 “Arthur”: 41 year old Bangladeshi man Resident in London x 10 years 11 week holiday in Bangladesh, returning in April 2008 Presented to HTD with a nine day history of fever & rigors No localising symptoms or signs Investigations: Hb 14.2 gm/dL CRP ALT WCC 3.8 x 109/L P 161 x 109/L Lymph: 1.31 x 109/L (> 1.5) 12 92 Malaria film – negative x 3 Blood cultures – negative x 5 Stool & urine culture – negative Allowed home after six days, presumed viral illness Re-admitted nine days later Persisting fever & rigors Clinically, febrile 40 C, clammy, unwell “Typhoid facies” Re-admitted nine days later Persisting fever & rigors Clinically, febrile 40 C, clammy, unwell “Typhoid facies” CRP 12 → 106 Blood & bone marrow cultures: S. typhi Reference laboratory: Rx: Resistant to: nalidixic acid chloramphenicol ciprofloxacin Sensitive to: ceftriaxone ceftriaxone & azithromycin full recovery Enteric fever • Salmonella enterica serovar typhi (S. typhi) and S. paratyphi A, B, C • Developing countries: 100 cases per 105 population / year • Globally: 16 to 33 million cases / year with 500-600 000 deaths • Returning travellers: 3-30 per 100 000 J.P. Duguid and J.F. Wilkinson; www.brittanica.com WHO. Typhoid vaccine {online} Crump J.A. et al., Bull. World Health Organ 2004; 82: 346-53 Steffen R. et al., J.Infect.Dis. 1987; 156:84-91 Cases of Enteric Fever- UK, HPA data • UK cases increasing • High rates of drug resistance particularly from Pakistan • A study of typhoid fever in five Asian countries: disease burden and implications for controls R Leon Ochiai et al. WHO data • The emergence of antibiotic resistance in typhoid fever Original Research Article Travel Medicine and Infectious Disease, Volume 2, Issue 2, May 2004, Pages 67-74 Fiona J. Cooke, John Wain Learning points • South Asia most common source of enteric fever in returning travellers, particularly VFRs • Most cases present within 4 weeks of return • S. paratyphi as likely as S.typhi • WCC invariably normal • Negative blood cultures does not always exclude the diagnosis “Arthur” 48 year old Caucasian man Consultant on golf course design Married 20 years, 4 children Minimal alcohol Working in Thailand intermittently for 18 months Most recently one month up to Christmas 2006 Malarone as antimalarial prophylaxis, no other drugs Fully vaccinated against hepatitis A, 2 doses of hepatitis B vaccine 1 year previously PMH nil of note January 2007: 10 day history of dark urine pale stool pruritis++ yellow eyes Clinically icteric++ Afebrile Palpable liver, 3 fingers’ breath below the right costal margin Excoriation++ trunk Otherwise NAD Investigations Hb 16.9 gm/dL WCC 5.2 x 109/L Plts 250 x 109/L U&Es normal Bilirubin 292 ALT 5806 Albumin 46 INR 1.1 Alk Phos 244 Hepatitis serology Hepatitis A IgG positive Hepatitis C negative Hepatitis E negative Hepatitis B surface antigen positive Anti-HB core IgM positive HBe antigen positive May 2007 Hepatitis B viral load negative Surface antigen not detected Anti-HBe positive ALT- normal Hepatitis E • Enterically transmitted, RNA Virus • Common in environments with poor sanitation • Outbreaks in industrialised countries • Seroprevalence from Bristol (UK) blood donors 16%, in China above 40%, in USA 36% Hepatitis E 350 No of Confirmed Cases 300 250 200 150 100 50 0 1 2003 Cases of Hepatitis A per Year http://www.hpa.org.uk/web/HPAweb&HPAwebStan dard/HPAweb_C/1279888997798 2 2004 3 2005 20092010 4 2006 5 2007 6 2008 7 2009 Cases of Hepatitis E per Year http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsA Z/HepatitisE/Surveillance/ Latin America 3% Sri Lanka 5% Sudan 3% Afganistan 3% India 21% All over SE Asia 7% Bangladesh 35% No Travel 38% Pakistan 10% Pakistan 5% Latin America 5% Madagascar 5% Africa 21% Hepatitis A 8 2010 Year India 39% Hepatitis E “Arthur” 22 year old Caucasian man 15th Sept to 30th August the following year travelling in south-east Asia, Australasia and Mexico 4 days after returning: fatigue, dizziness and fever 2 weeks later presented to hospital No history of bloody diarrhoea Weight loss of 8kg Clinically: Unwell, anaemic, icteric Febrile 38.5 °C Probably dry Right basal effusion Grossly enlarged, tender liver Fluctuant area in right hypochondrium PHM: nil of note Drug history: nil No antimalarial prophylaxis Minimal alcohol Investigations: Hb 10.0 gm/dL WCC 22.0 109/L Plts 430 109/L Na 131 CRP 168 Bilirubin 30 ALT 120 AlkP 141 Alb 26 Ultrasound appearances Liver abscess 14 x 11 x 11 cm Aspirated under LA 150 ml turbid pus “Anchovy sauce:” Amoebic Liver Abscess Amoebic serology positive Stool OCP: Entamoeba histolytic Treatment of amoebiasis Tissue parasites Metronidazole Tinidazole In the gut lumen Paromomycin Diloxanide furoate Gut wall Liver Rx Tinidazole + Diloxanide furoate Observed for 10 days Symptomatic improvement Allowed home Readmitted one week later: Worsening RUQ pain No fever Repeat ultrasound: 2 large abscesses left lobe 14 x 13 x 13 cm, right lobe 14 x 13 x 10 cm Drains inserted under U/S guidance 1400ml pus from left abscess, 1000ml from right Dramatic resolution of symptoms Trophozoite and Cyst forms of Entamoeba histolytica/dispar • ____ 10 µm Differential Diagnosis of ALA Pyogenic liver abscess Cryptogenic (primary) Secondary to intra-abdominal sepsis Infected hydatid cyst (15% of hydatid cases in one series) Hepatocellular carcinoma Necrotic Bleeding into the tumour Summary • Gastrointestinal illness post travel very common • Many cases self- limiting • More common when visiting less developed countries • Often associated with a breakdown in hygiene Acknowledgements • Maggie Armstrong, Tom Doherty, Trupti Patel HTD- many of the slides