1. Fever in the Tropics Tom D. Thacher, MD Department of Family Medicine Mayo Clinic, Rochester, Minnesota thacher.thomas@mayo.edu

3. 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

5. Learning Objectives 1. Syndromic Approach 2. 8 Febrile Syndromes

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

7. Empiric treatment Syndromic Approach

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

9. 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

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

11. 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

12. Okie S. N Engl J Med 2008;358:2425-2428 Malaria

13. Plasmodium falciparum

14. 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

15. Typhoid Fever

16. 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 www.worldortho.med.usyd.edu.au

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

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

20. 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

21. Relapsing Fever

22. 8 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Bone and joint 8. Gynecologic

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

25. African Meningitis Belt

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

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

30. 8 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Bone and joint 8. Gynecologic

31. 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

32. 8 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Bone and joint 8. Gynecologic

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

34. Causes of Death in Children Under Age 5 Years in Africa

36. 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

43. 8 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Bone and joint 8. Gynecologic

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

53. 8 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Bone and joint 8. Gynecologic

54. 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

55. 8 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Bone and joint 8. Gynecologic

56. 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

59. 8 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Bone and joint 8. Gynecologic

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

61. 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

62. What is the deadliest animal in Africa?

63. no-pest.com

64. no-pest.com

65. news.nationalgeographic.com 20,000 deaths per year

66. 800,000 deaths per year