Transcript Evaluation of Diarrhea, and Fever in the Returned Traveler

Evaluation of Illness in
the
Returned Traveler
Jean Haulman MD
Hall Health Primary Care Center
University of Washington
ACHA May 27, 2008
Your favorite
exotic disease
is only an
airplane ride
away
About 30 million Americans go abroad
each year
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8 million will go to less developed
countries
7 million will go where there is risk of
malaria
223,000 American university students
studied abroad in 2005-2006
• European destinations remained flat
• Study in less developed countries rose
• Middle East up 31%
• Asia up 26%
• Latin America up 14%
True risk
Traffic accidents
(exotic and
non-exotic)
remain the
leading cause
of death in
foreign
travelers
Most Common Illness in Returned
Travelers
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Diarrhea: 46%
• Travelers’ diarrhea 34%
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Respiratory Illness: 26%
Skin problems: 8%
Acute mountain sickness: 8%
Motion sickness: 5%
Isolated febrile illness: 3%
DIARRHEA
A.K.A.
Montezuma’s revenge
Aztec two-step
The trots
Turkey Trots
Turista
Distribution of TD
Why is diarrhea more common
in the developing world?
Travelers’ diarrhea
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Risk increases in
travelers going to
less developed
country
Food is the vector
for travelers’
diarrhea more often
than water
Travelers’ diarrhea
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>/= 3 or more unformed stools in 24
hours
Associated with N, V, T, cramps, urgency
Usually an acute, self-limiting illness;
resolves within about 5 days.
3-10% of pts with TD will have symptoms
lasting longer than 2 weeks.
Up to 3% of travelers have diarrhea
lasting over 30 days, some long term
Most symptoms occur while abroad
Self-treatment for bacteria
associated with TD
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Most of the world:
• ETEC (enterotoxigenic E. coli)
• Self-treatment: fluoroquinolone
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Southeast Asia:
• FQ-resistant Campylobacter.
• Self-treatment: macrolide
Labs for diarrhea
• Do nothing if diarrhea is mild and
present less than 5-7 days
• Stool O&P + Giardia Ag
• Stool C&S x 1
• Stool C. difficile if history of antibiotic
or antimalarial use
• CBC with diff
• U/A
TD Pearls
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Not all diarrhea that begins during or
immediately after international travel
is related to that travel.
No positive lab findings  “You’re
fine.”
P. falciparum can present as diarrhea
and fever.
Travelers want to spend time
here
--not here--
Fever and Illness in the returned
traveler
2-3% of international travelers develop fever
during or immediately after their trip.
Fever in the Returned Traveler
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The differential
diagnosis of fever
in the returned
traveler is LARGE
The diagnoses
accounting for
most of the causes
of fever is small
Most common cause of fever in the
returned traveler
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Malaria
URI/LRI
Diarrhea/dysentery
Dengue
Hepatitis (us. A)
UTI
Typhoid fever
27-42%
3-24%
5-14%
2-8%
3-6%
2-4%
2-3%
Non Infectious Sources of Fever
• DVT, PE
• Serum sickness
• Malignancy
• Collagen Vascular Disease
How to approach the
evaluation of the ill, often
febrile, returned traveler
systematically
Remember all fever in returning traveler from endemic
country is malaria until proven otherwise AND all patients
seen with fever in developing countries have a good chance
of being treated for malaria
History
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Destination country, season
Exposure history: planned activities,
accommodations, food, water, swimming
holes, new sexual partner, etc
Incubation period: when did fever or
symptoms start?
Pre-travel vaccinations and malaria meds
General health and immune system status
Characteristic Findings
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Physical
• Vital signs
• Skin findings including bite marks
• Joint, Respiratory, GI, Neuro Sxs
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Labs
• Eosinophilia
• Leukopenia, Thrombocytopenia
• LFTs
1. Travel location(s) and
duration of stay
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The longer the stay in a developing
country the greater the risk of travel
related illness
Short stays are considered <2-3 weeks
Long stays are > 1 month
The destination may include or exclude
certain illness that follow geographic
patterns and seasons
Yellow Fever
Meningococcal Infections
2. Accommodations
http://www.arr-the-kraken.com/images/oz_02.jpg
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Accommodations
• Accommodations:
Hotel, tent, hostel,
cave
• City vs. rural
http://pro.corbis.com/images
http://ritz-carlton-boston-commons.visit-boston-massachusetts.com/boston-ritz-carlton-suite.jpg
Activities/ Accommodations
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Reason for travel
• backpacking,
• Hiking/ trekking
• spelunking
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Caves
• rabies (bat bite, or
bat guano
inhalation)
• Histoplasmosis
Accommodations
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Crowded living conditions, group
travel, exposure to ill persons:
• Meningococcal disease
• Influenza
• Tuberculosis
• VHFS: Lassa, Marburg, Ebola
• Hepatitis A
Lassa Fever- Rodents
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Mastomys rat, West Africa
Most common directly transmissible VHF
of international travelers.
Acquire disease by
• Inhaling urine, feces of rat
• Open skin contact with urine/ feces
• Eating the rodent
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Incubation: 1-3 weeks
Acute viral illness, 80% asymptomatic,
5000 deaths/ yr
MMWR: October 1, 2004 / 53(38);894-897
Lassa Fever
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Gradual onset: H/A, fever, malaise
GI and Respiratory symptoms
Deafness: most common
complication (1/3)
Severe multisystem disease
Dx with ELISA: IgM and IgG
antibodies
Person to person spread (body fluids
aerosolized)
3. Exposure History
Types
 Food and Water
 Mosquitoes, ticks, sand flies, and
other bugs
 Animals
 New Sexual Partners
 Freshwater
Exposure: Food and water
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Hepatitis A
Toxoplasmosis
Trichinella
Enteric fever
(typhoid,
paratyphoid)
Bacterial
gastroenteritis
Amoebiasis
www.nal.usda.gov/.../fsheets/fsheet04.htm
www.the-travel-doctor.com/typhoidfever.htm
Water: Enteric Fever
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Caused by Salmonella
typhi or S. paratyphi
High fever with
relative bradycardia
Normal WBC count
Blood culture: + 80%
Bone marrow
aspirate: + 90%
Serology
Vaccine is only 50% to
70% efficacious
Enteric fever
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16 million cases/ worldwide/year
200 to 400 positive labs in the US
• 75% in VFRs
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6 top countries
• INDIA, Pakistan, Bangladesh
• Mexico
• Philippines
• Haiti
Exposure: arthropods
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Mosquitoes
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Malaria
Dengue
Yellow fever
JEV
West Nile Virus
Rift Valley Fever: subSaharan Africa
• Chikungunya
• Others
www.saudeanimal.con.by/imagens/dengue1.htm
Dengue
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Most widespread arbovirus
Daytime biting mosquito
4 serotypes
• No cross serotype coverage
• Prior dengue fever with one serotype
predisposes to the risk of a more
serious hemorrhagic disease with
future exposure
Dengue: Clinical Symptoms
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Incubation period: 3 to 8 days
Acute onset high fever, lasting 5 days
SEVERE myalgias: “break bone
fever”
Retro-orbital H/A, cervical
adenopathy
Rash: MP to hemorrhagic, may mimic
Rubeolla
Dengue Fever Distribution
www.cdc.gov
Mosquitoes: Yellow Fever
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High fever, headache, malaise, back
ache
3-6 days following mosquito bite
Shock, liver/ renal failure
AFRICA and South America
50% mortality
Yellow Fever Distribution
www.traveldoctor.co,uk/yellowfever.htm
Mosquitoes: Japanese
Encephalitis
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Asia: majority subclinical
Mild infections: fever with headache.
More severe infection: sudden onset
headache, high fever, neck stiffness,
stupor, coma, occasional convulsions
and spastic paralysis.
Vaccination recommendations are
seasonal
JE World Distribution
Source: Tsai TR, Chang GW, Yu YX. Japanese encephalitis vaccines. In Plotkin SA and Orenstein
WA, eds., Vaccines - 3rd edition, WB Saunders, Inc., Philadelphia, PA, 1999;672-710.
Malaria
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Fever = Malaria
Majority of cases
• P falciparum
• P. vivax
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VFRs: immunity
wanes
Risks
• AFRICA
• India and SE Asia
• Americas
Anopheles mosquito: courtesy of Chris Sanford MD
Exposure: Ticks
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Rocky Mountain spotted fever
Crimean-Congo hemorrhagic fever
Relapsing fever (Borrelia sp.)
Lyme disease
Tularemia
Babesiosis
www.imc-la.com/ cbr/L1C-m2.html
Exposure:
sand flies
AARP.org
• Leishmaniasis
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http://www.biomedcentral.com
Visceral: fever, weight loss, HSM, anemia
Develops months to years after exposure
Most common form: cutaneous
• Bartonellosis (Oroya fever)
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http://earthobservatory.nasa.gov/Newsr
oom/NasaNews/2002/200201177310.ht
ml
W. South America (Peru)
Fever, H/A, anemia, migratory joint and
muscle pain
Chronic form: painful dermal nodules
Exposure: Other bugs
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Tsetse flies
• African trypanosomiasis (Af. sleeping dz)
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Reduviid bugs
• American trypanosomiasis (Chagas’ disease)
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Chiggers
• Scrub typhus
Exposure
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Deer flies
• Loa loa: eye worm
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Black flies
• Onchocerciasis (river
blindness)
www.biosci.ohio-state.edu/ ~parasite/loa.html
http://www.asnom.org/image/442
Exposure
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Tsetse flies: African
trypanosomiasis (African
sleeping disease)
T.b. gambiense (west)
• Fever, H/A, joint pain
• CNS later
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T.b. rhodesiense (east)
• Fever with rapid systemic
symptoms
• HSM
• Anemia, jaundice
Bugs: Chagas’
Disease
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American
trypanosomiasis
Romana’s sign
Reduviid bugs
Live in cracks in mud
walls, flooring
Fever 1-2 weeks
Lymph, HSM
Chronic 10-20 years
http://woub.org/intouch/Tropical_Disease/tropical_disease.html
Chiggers : Scrub typhus
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SE Asia and SW
Pacific
Bite: ulcerates
6-18 days post bite
Sudden T> 104,
severe H/A, myalgia,
relative bradycardia
End of first week:
Rash, HSM, general
adenopathy
Exposure
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Animals
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Rabies
Tularemia
Q fever
Anthrax
Plague
Viral hemorrhagic
fevers (Lassa, etc.)
Ticks/ Animals: Tularemia
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Tick bite:
ulceroglandular form
Broken skin contact
with carcass
Inhalation
Ingestion of meat,
contaminated water
NA, Europe, Asia
“Atypical pneumonia”
Axillary nodes, fever,
H/A, SOB, joint pain
Category A
bioterrorism
http://www.rnceus.com/biot/tula.html
Exposure: New sexual partners
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HIV
Hepatitis B
Other STDS: herpes, gonorrhea,
syphilis, HPV, lymphogranularum
inguinal
Swimming Exposure Fresh water
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Schistosomiasis
Leptospirosis
Hepatitis A
Schistosomiasis
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Parasite penetrates human skin
Migrate to blood stream
Katayama fever: S. mansoni
• fever, headache, cough, transitory hives,
lymphadenopathy, HSM, eosinophilia
• Mid East, Africa, eastern S. America and
Carribean
• Transverse myelitis
Fresh Water: Leptospirosis
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Most common zoonosis worldwide
Spirochyte that lives in kidney
Agricultural: Rice/sugarcane
workers/farmers
Recreational: adventure traveler,
fisherman, Borneo 2000
Rats/mice, mongooses/dogs, pigs/cattle
Animal urine contaminates water and soil
Leptospirosis
Courtesy of Elaine Jong MD
Fresh Water: Leptospirosis
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Incubation 7 to 14 days
Abrupt fever> 39, chills
Frontal H/A (“worst H/A of life”)
Muscle pains
GI
Pulm: cough, hemoptysis, CP
Rash
Later: Aseptic meningitis, iritis/ uveitis,
possible psychiatric symptoms
4. Incubation period: <21 days:
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Malaria
Dengue
Yellow fever
Japanese encephalitis
Meningococcemia
Leptospirosis
Typhoid fever
East African trypanosomiasis
4. Incubation period: >21 days
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Malaria (esp. after ineffective
prophylaxis)
Acute HIV
Acute systemic Schistosomiasis
(Katayama fever)
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Viral hepatitis (A, B, C, D, E)
Tuberculosis
Leishmaniasis
West African trypanosomiasis
5. Pre-travel preparations
• Immunizations
• Assess malaria risk
• use of personal protection measures
(DEET, permethrin, bed net)
• was patient bitten by insects?
• compliance re malaria prophylaxis
• appropriate malaria prophylaxis
Work up Laboratory tests
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Everyone with post travel fever
(>101):
• CBC with diff: eosinophilia is abnormal
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If potential for malaria
• thick and thin blood smear(s)
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Consider saving a tube of serum
(acute-phase sample) for later
serology
Laboratory tests
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Consider
• LFTs: Mild elevations (2-3 x upper
range of normal) --non-specific. Marked
elevation suggests acute hepatitis.
• Stool studies
• CXR if symptomatic
• PPD
Case 1: 23 y.o. Nursing Student
Returns from 3 week stay with relatives in
rural India
• High fever
• Constipation early, now N,V,D
• HR 60, BP 90/60.
• Had hepatitis A vaccine prior to trip
• Appears very ill
• Denies mosquito bites and took malaria
prophylaxis daily
Case 2.
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27 y.o. anthropology TA returns from
10 day dig in Bolivia
Multiple insect bites
Rural areas, stayed in local housing
Sudden onset fever, H/A, myalgias
Anemia and thrombocytopenia
Bites are not infected, no purpura,
no cough
Possible Diagnoses
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MALARIA
Dengue
American Trypanosomiasis
Bartonellosis
Why not Scrub typhus or JEV?
Case #3
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21 y/o female student returns from 3
mo July through September trip to
Botswana in Okayonga delta
Did some hiking in rural areas, had
to cross small stream early in her
trip
Has fever, headache, myalgias, sore
throat, joint aches, fatigue and
swollen cervical nodes
Case #3
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VS Temp 100.7, RR 20, Pulse 80, BP
100/72
Appeared slightly ill
Skin warm, dry
No rash or obvious bites
+cervical nodes
Injected pharynx
Heart, lungs, abdomen, joints normal
Diagnosis?
Case #3
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Strep Pharyngitis, Mono
Influenza from Southern hemisphere
Malaria: non-malaria season
Dengue: normal CBC
Schistosmiasis: no eosinophils
Leptospirosis: 7-10 days incubation
Other history
Case 4. 27 y.o. medical student
returned from SE Asia
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Usually healthy woman with fever,
arthralgias; did have diarrhea
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In India, Laos, Thailand, Burma (Feb-Mar)
intermittent use of DEET and bed net
no fresh water or animal exposure
Low budget accommodations
sexually active. BC: condoms. LMP: 5 weeks
prior to first visit with post-travel physician.
• medications: doxycycline for acne (used this
for malaria prophylaxis too)
Work up
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Labs: multiple malaria smears - negative
CBC: mild anemia, slight leukopenia,
borderline thrombocytopenia
blood culture: negative
UA: negative
CXR: normal
PPD: 0 mm induration
Urine pregnancy test: negative.
Diagnostic possibilities
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Dengue, Chikungunya, JEV
Scrub typhus
Reiters’ post dysentery
RF: negative
ANA: positive at 1:320 titer. Pattern:
diffuse. Anti-ss DNA present.
Case study: post-travel fever
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Doxycycline stopped followed by all
symptoms clearing within a few
weeks.
Final diagnosis: drug-induced lupus.
Post travel Questions
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Where did you go?
When were you there and how long did
you stay? Where did you stay?
What did you do or not do?
What did you drink?
Where did you swim?
When did you become ill?
What meds did you take?
What vaccines have you had?
Many Thanks
Jean Haulman MD
Bibliography
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DuPont HL, Steffen R (eds.): Textbook of Travel
Medicine and Health, 2nd Ed. B.C. Decker, 2001.
Keystone JS, Kozarsky PE, Freedman DO, et al,
eds: Travel Medicine. Mosby, 2004.
McLellan, SLF: Evaluation of fever in the returned
traveler. In Sanford C (guest ed.) Primary Care
Clinics: Travel medicine. Saunders/Elsevier Dec
2002.
International Travel Health Guide & National
Travel Health Network and Centre
Sanford C. (guest editor): Primary Care Clinics:
Travel Medicine. Sauners/Elsevier, December
2002.