Tropical problems in the returning traveller Ravi Gowda Infection and Tropical Medicine UHCW May 2011

Outline An approach to the ill returning traveller in 10 mins Application of this approach to clinical cases Mini picture quiz

Why is this subject important in Coventry?

Coventrys ethnic diversity 2001 census Ethnic group% Total Population % White British78.3% White Other2.2% Indian8% Pakistani2.1% Black Caribbean1.1% Black African0.6% Black Other0.1% Chinese or other ethnic group: Chinese 0.7%

World travel Students 2 universities Coventry college Lecturers Elective students: medics, nurses Visiting family and friends

An approach to the febrile patient – 4 questions in 10 mins Where? When? Why? What?

An approach to the febrile patient – 4 questions in your 10 mins Where? When? Why? What?

Where? Details of travel –Malaria endemic country? –Yellow fever only occurs in Africa and South America –Dengue and Chikungunya in SE Asia (Fever, arthralgia and rash: FAR)

Where? Was the area urban or rural? Forested, or high altitude? For example, transmission of malaria is less likely at altitudes over 2000 metres.

An approach to the febrile patient – 4 questions in your 10 mins Where? When? Why? What?

When? When did they go? When did they return? When did the symptoms start? Was it the rainy season? Increased risk of vector borne diseases Allows calculation of incubation periods

Incubation period of common infections SHORT (<10 days) –Arboviral infections eg Dengue,chikungunya –Gastroenteritis –Typhus (louse and flea borne) – Plague –Viral Haemorrhagic fever

Incubation period of common infections MEDIUM Malaria - Enteric fever - Scrub typhus - African trypanosomiasis - Brucellosis - Leptospirosis

Incubation period of common infections LONG (>21 days) - Viral hepatitis - Malaria - TB - HIV - Schistosomiasis - Visceral leishmaniasis - Filariasis - Amoebic liver abscess

When? Helps to work out incubation periods If onset of symptoms starts >21 days after return, most imported infections ruled out except… –HIV –Malaria –TB –Leishmaniasis –Chronic Schistosomiasis

An approach to the febrile patient – 4 questions in your 10 mins Where? When? Why? What?

Why? Did they go for sex? Whom did they have sex with?

An approach to the febrile patient – 4 questions in your 10 mins Where? When? Why? What?

Did the traveller going to a refugee camp as a humanitarian aid worker …. or attend a game reserve?

What? The level of risk from diseases will vary greatly depending upon the type of terrain and facilities available Package holiday? –Low risk

What vaccinations and prophylaxis? Effective –Hep A –Hep B –Japanese encephalitis –Yellow fever Partially effective –Typhoid –TB –Malaria prophylaxis

Exposure and Tropical infections Raw/undercooked foods – enteric infections, hepatitis, trichinosis Fresh water swimming – schistosomiasis, leptospirosis

Exposure and Tropical infections Insect bites – malaria, rickettsial infections, dengue, trypanosomiasis Animal - Q fever, anthrax, rabies Human - viral haemorrhagic fever

Clinical Syndromes Fever, rash, arthalgia (FAR) - arboviral infections, dengue. <10 days Fever, rash, sore throat, lymphadenopathy - HIV seroconversion illness, EBV, streptococcal pharyngitis

Physical signs aiding diagnosis Jaundice – malaria, hepatitis, leptospirosis, yellow fever, glandular fever Hepatomegaly – malaria, hepatitis, leptospirosis, typhoid, brucella

Physical signs aiding diagnosis Eschar – tick typhus, Crimean-Congo Haemorrhagic Fever, anthrax Haemorrhage – Viral haemorrhagic fever, yellow fever, dengue, rickettsial infections (eg Rocky mountain spotted fever)

New Eng J Med 2009

Initial screen puo FBC,ESR, U+E, LFTS,CRP, (blood cultures) Malaria Film Urine, stool (ova, cysts and parasites, M+C+S) CXR

Initial tropical eosinophilia screen FBC,ESR, U+E, LFTS,CRP, Urine for Schistosomiasis (if applicable) 3 stools for ova, cysts and parasites, M+C+S CXR Serology for schistosomiasis, strongyloides, filiariasis, amoebiasis, hydatid

Causes of fever in the returning Traveller

Awareness of geographical distribution of infections

Yellow fever risk areas-Africa Nathnac.org

Case 1 85 yr old caucasian 2/52 fever, sweats and wt loss PMH - nil Where? –rural Portugal, Algarve –Malta

Case 1 When –Portugal 4 months ago –Malta 20 yrs ago –2 Weeks

Case 1 What and Why? –Villa holiday. Walking in surrounding countryside –Went with his longstanding wife Hb.9.6 wcc 2.6 Plt 50 Bone marrow –Myelodysplasia

Case 1 Leishmania serology positive Leishmania pcr positive in bone marrow Diagnosis –Visceral leishmaniasis

Leishmaniasis - Life cycle lifecycle

Global distribution of leishmaniasis

Leishmania- key messages Think of leishmaniasis in any patient with a fever >2 wks and a hepato- splenomegaly…. and has lived or travelled in an endemic area

Case 2 54yr old lady admitted with 3/7 headache and fever. Admitted last week Where? –India (Mumbai, Gujarat), Fiji When? –July/August 2010 –Returned end of August

Case 2 Why? –Denies any risky behaviour What? –Visiting friends and relatives, and tourist sites –Malaria prophylaxis (chloroquine) –Hx and exam. NAD

Case 2 - Investigations FBC, ESR CXR U+E, LFTS CRP - 48

Case 1 Picture film

Diagnosis Vivax malaria

Key message Consider malaria in any traveller with fever returning from an endemic area … Even if they have received prophylaxis

Case 3 43yr sports retail executive Flores, Indonesia 10 days Symptoms started 3/7 after return

Case 3 Scuba diving trip Fever, headache, joint pains C/o of generalised rash 2/7 prior to admission

Case 3 Fading generalised, erythematous rash Bloods –Hb 13.1 –wcc, 2.1 –Neutrophils 0.8 –Lymphocytes 0.74 –Platelets 68 –Malaria film negative

Case 3 Acute Dengue – IgM positive – IgG negative Convalescent Dengue 6 weeks later –IgM negative – IgG positive

Diagnosis Acute Dengue Fever

Key messages Dengue is common 100 million cases pa worldwide Consider the diagnosis in the fever, arthalgia, rash syndrome (FAR) in travellers returning from endemic area

Case 4 32 yr IT engineer Profuse watery diarrhoea 2/7 Slightly blood stained 2/52 in Kashmir Symptoms on flight back to the UK

Case 4 Visiting friends and relatives Went with his wife Went to his ancestral village and attended weddings Typhoid vaccine Malaria prophylaxis

Case 4 High fevers, rigors on the flight back Felt profoundly unwell 39.2°c, pulse 122, BP 80/62, dehydrated Wcc 17, crp 243 Admitted to ITU; pouring fluid out, acute renal failure

Investigations?

Stool O,C,P and M+C+S

Diagnosis Shigella dysentery

Learning points Most causes of travellers diarrhoea caused by Salmonella, Campylobacter, E coli Consider Shigella, giardia Remember enteric fever is a septicaemia: Fever, headache and dry cough, diarrhoea uncommon

Case 5 49yr old GP Admitted with 10/7 fever Overland safari camping trip to Southern Africa Malawi, Zambia, lower Zambezi river Kafue national park 4 week trip Symptoms start 7 days after return

Case 5 Fever Swelling and inflammation of left side of the face with localised enlargement of lymph nodes Diarrhoea PMH - hyperthyroid

Differential? Textbook of infectious diseases Nathnac.org Travax.co.uk

Differential Malaria Infective gastroenteritis Rickettsial infections –African tick typhus Other

Investigations Blood cultures Thick and thin film Serology

Diagnosis African Trypanosomiasis