Fever in the Tropics Tom D. Thacher, MD Department of Family Medicine Mayo Clinic, Rochester, Minnesota

Fever as a Symptom 1. Malaria 2. Hypertension 3. Dyspepsia 4. Pulmonary tuberculosis 5. Medical examination 6. Upper respiratory infection 7. Urinary tract infection 8. HIV infection 9. Diabetes mellitus 10. PID 1/3 of all presentations in primary care

Learning Objectives 1. Syndromic Approach 2. 8 Febrile Syndromes

Context of Fever Age Age Geography Geography Season Season Duration of fever Duration of fever Malnutrition Malnutrition Immune status Immune status Exposures Exposures

Empiric treatment Syndromic Approach

8 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Bone and joint 8. Gynecologic

Which of these is NOT in the top five causes of death in children in tropical countries? A. Measles B. Pneumonia C. Typhoid D. HIV E. Malaria

Causes of Death in Children Under Age 5 Years in Africa 2/3 of all child deaths

1.Fever Alone Malaria Malaria Typhoid fever Typhoid fever HIV HIV Dengue Dengue Leptospirosis Leptospirosis Rickettsia Rickettsia Relapsing fever Relapsing fever Other viral illnesses Other viral illnesses

Okie S. N Engl J Med 2008;358: Malaria

Plasmodium falciparum

Symptoms of malaria Headache Headache Pallor Pallor Severe hemolytic anemia Severe hemolytic anemia Heart failure Heart failure Cerebral malaria – impaired mental status, convulsions, coma Cerebral malaria – impaired mental status, convulsions, coma Labored breathing Labored breathing acidosis, heart failure acidosis, heart failure Splenomegaly Splenomegaly

Typhoid Fever

Typhoid Sustained high fever, headache Sustained high fever, headache Apathy, psychosis Apathy, psychosis Constipation, abdominal pain Constipation, abdominal pain Splenomegaly Splenomegaly Positive blood culture Positive blood culture

Dengue Asia, So. America Asia, So. America Marked myalgia, eye pain Marked myalgia, eye pain Rash Rash ↓ WBC, ↓ platelets ↓ WBC, ↓ platelets

Leptospirosis Rash Rash Aseptic meningitis Aseptic meningitis Clue: conjunctival injection Clue: conjunctival injection

Rickettsia Fever, headache, and myalgia Fever, headache, and myalgia Clue: tick exposure, painless eschar Clue: tick exposure, painless eschar African tick-bite fever, scrub typhus African tick-bite fever, scrub typhus

Relapsing Fever

8 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Bone and joint 8. Gynecologic

2.Neurologic Syndromes Fever, headache, altered mental status, convulsions, coma Cerebral malaria Cerebral malaria Meningitis Meningitis Encephalitis Encephalitis HIV HIV

African Meningitis Belt

Encephalitis Rabies Rabies Japanese encephalitis Japanese encephalitis West Nile encephalitis West Nile encephalitis Trypanosomiasis (sleeping sickness) Trypanosomiasis (sleeping sickness)

HIV Chronic Meningitis: TB, cryptococcal Chronic Meningitis: TB, cryptococcal Toxoplasmosis Toxoplasmosis HIV dementia HIV dementia

8 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Bone and joint 8. Gynecologic

3.Abdominal Syndromes Fever, abdominal pain Typhoid Typhoid Infectious colitis: shigella, E. coli, salmonella, campylobacter, ameba Infectious colitis: shigella, E. coli, salmonella, campylobacter, ameba Amebic liver abscess Amebic liver abscess Abdominal TB Abdominal TB Appendicitis, pyelonephritis Appendicitis, pyelonephritis HIV HIV

8 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Bone and joint 8. Gynecologic

4.Pulmonary Syndromes Fever, cough, dyspnea Pneumonia Pneumonia Tuberculosis Tuberculosis HIV HIV

Causes of Death in Children Under Age 5 Years in Africa

IMCI Integrated Management of Childhood Illness Increased respiratory rate Increased respiratory rate ≥60 if age < 2 mos. ≥60 if age < 2 mos. ≥50 if age 2-12 mos. ≥50 if age 2-12 mos. ≥40 if age 12 mos. to 5 years ≥40 if age 12 mos. to 5 years Lower chest retractions Lower chest retractions

8 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Bone and joint 8. Gynecologic

5.Rash Syndromes Fever and skin rash Measles Measles HIV HIV Dengue Dengue Other viruses Other viruses

8 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Bone and joint 8. Gynecologic

6.Hemorrhagic Syndromes Hematemesis, melena, epistaxis, petechiae, purpura, puncture site bleeding Ebola, Lassa, Marburg Ebola, Lassa, Marburg Yellow fever Yellow fever Dengue Dengue Relapsing fever Relapsing fever

8 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Bone and joint 8. Gynecologic

7.Musculoskeletal Syndromes Fever with joint or bone pain Sickle cell disease Sickle cell disease Septic arthritis Septic arthritis Osteomyelitis Osteomyelitis Pyomyositis Pyomyositis Rheumatic fever Rheumatic fever

8 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Bone and joint 8. Gynecologic

8.Gynecologic Syndromes Fever, pelvic pain, vaginal discharge PID PID Tubo-ovarian abscess Tubo-ovarian abscess Postpartum endometritis Postpartum endometritis Septic abortion Septic abortion

Treatment Limiting Factors Self treatment with OTC antibiotics Self treatment with OTC antibiotics Limited spectrum of antibiotics Limited spectrum of antibiotics No health insurance No health insurance Counterfeit drugs and adulteration Counterfeit drugs and adulteration

What is the deadliest animal in Africa?

no-pest.com

no-pest.com

news.nationalgeographic.com 20,000 deaths per year

800,000 deaths per year