Transcript Slide 1

The Returning Traveller
Dr Catherine Cosgrove
MBBS MRCP PhD DipHIV
Senior Clinical Lecturer and
Honorary Consultant in Infectious Diseases
Objectives
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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
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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
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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
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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
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A study of typhoid fever in five Asian countries:
disease burden and implications for controls
R Leon Ochiai et al. WHO data
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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/
L atin A meric a
3%
Sri L anka
5%
Sudan
3%
A fganis tan
3%
I ndia
21%
A ll over SE A s ia
7%
Banglades h
35%
N o T ravel
38%
P akis tan
10%
P akis tan
5%
L atin A meric a
5%
M adagas c ar
5%
A fric a
21%
Hepatitis A
8
2010
Year
I ndia
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
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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