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travel_fever

the febrile returned traveller

introduction

  • infections in the returned traveller:
    • 50% of travellers returning to Europe and North America from the tropics experience health problems related to their travel, and 8% consult doctors either abroad or on return
    • 90% of infections related to short-term travel present within six months of return
    • older travellers are more likely to have a febrile complication of underlying disease, such as endocarditis or pneumonia.
    • typhoid and paratyphoid - typhoid vaccine confers about 70% protection for typhoid, so does not rule out the diagnosis
    • malaria - esp. West Africa (2%), Nigeria (1.3%), the Solomon Islands (1.1%), Ghana (0.6%) and Papua New Guinea (0.4%) without prophylaxis. TEST ALL FEBRILE travellers from endemic regions within past 12 months.
    • dengue fever - maculopapular rash, thrombocytopenia and leukopenia
    • zika virus and other arthropod borne viral infections
    • traveller's diarrhoea (35% incidence per month of travel)
      • most due to enterotoxigenic Escherichia coli (ETEC).
    • acute respiratory infections
    • giardiasis (0.7%)
    • tuberculosis (TB) occurs in 2% of long-term travellers to high risk areas (subSaharan Africa, Nth Africa, Sth and East Asia, Middle East, Central and Sth America)
    • animal bites - rabies
    • delayed presentations months later:
  • multi-resistant bacteria an increasing problem
    • Asia has high rates of resistant intestinal bacteria which may create issues for travelers if they acquire it (eg. over 80% will become carriers of carbapenem-resistant enterobacteriaceae (CRE) after a 2 week admission in Vietnam and 10% of ED patients were colonized with CRE according to a 2019 study1)) and then develop UTI, etc.
    • multidrug-resistant tuberculosis (TB) is endemic in many regions - according to WHO in 2017, each year around 0.5 million people will acquire it annually with highest rates in eastern Europe, then China, Middle East, and Peru 2)

incubation periods

short (< 10 days) intermediate (10-21 days) long (> 21 days)
influenza malaria malaria
dengue fever viral haemorrhagic fevers hepatitis A,B,C,D,E
yellow fever typhoid rabies
plague scrub typhus schistosomiasis
paratyphoid enteric fever Q fever leishmaniasis
Mediterranean spotted fever Relapsing fever amoebic liver abscesses
African tick-bite fever African trypanosomiasis tuberculosis (TB)
Rocky Mountain spotted fever filariasis
brucellosis

ED Mx of febrile returned traveller

severe sepsis

not severe sepsis

  • travel history - regions, dates, immunisations, check incubation periods
  • pattern of fever occasionally helpful - every 2 days for Pl. vivax
  • focal features eg. memingism, pneumonia, etc.
  • rash
  • investigations such as:
    • FBE, U&E, LFTs, blood cultures x 2, baseline serology
    • CXR
    • MSU m/c/s
    • specific Ix for focal findings
    • if possible malaria
      • thick and thin blood films, if negative, repeat 3 times
    • if rash
      • consider DDx as below
    • if respiratory symptoms:
      • if within 3 days of return, consider influenza
      • if pulmonary consolidation, consider legionaire's, meliodosis, and if severe, consider giving macrolide or quinolone
    • if fever > 7 days:
    • if jaundiced:

DDx of fever, maculopapular rash, thrombocytopenia and leukopenia

eosinophilia in the returned traveller

  • incidence in returned travellers from the tropics is ~5%
  • it is suggestive of parasite infection such as a helminth infection although the absence of eosinophilia does not exclude helminth infection as less than half have eosinophilia

common helminth infections from the tropics

initial Ix

  • three stool examinations for ova, cysts and parasites to detect the more common gastrointestinal helminths, whose eggs may be excreted intermittently
  • any macroscopically visible worms (likely to be ascarids or tapeworm) should be sent for laboratory identification
  • specific serological testing is available for schistosomiasis, strongyloidiasis, filariasis, echinococcosis, toxocariasis and angio-strongyliasis

empirical Rx of presumed helminth infection

  • start Rx after stool collections
  • options include mebendazole, pyrantel and albendazole although of these, only albendazole is useful for strongyloidiasis, tapeworm infection or schistosomiasis.
travel_fever.txt · Last modified: 2022/08/25 05:09 by gary1

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