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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.
    • 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 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:

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
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: 2018/01/03 02:47 by wh