1. Traveler with a fever Case presentation Ann Schmidt

2. CASE  68 yo woman presented to the ER with several day history of fever and one day history of confusion.

3. Past Medical History  NIDDM for several years, well controlled  Coronary heart disease with bypass grafting x 3 one year ago  Mild Hypertension

4. Social History  Has lived in Madison for >10 years but husband and some family members are still in Nigeria, her home town.  Lives alone  No pets  Nonsmoker  Rare Alcohol.

5. Family History  Positive for heart disease and diabetes.  No breast or colon cancer  Family members in the US are healthy.

6. Review of Systems  Family reports she was well on arrival home.  No initial fever, chills, sore throat, resp. illness or GI symptoms.  Her first complaint was arthralgias, followed by fevers to 102 – 105.  Mild confusion started on the day of admission, worsened by the afternoon.

7. ER evaluation  Labs – Normal CBC, glucose, electrolytes and BUN/Creatinine.  Head CT – normal  Chest X-ray – normal  Urinalysis – trace ketones, + 2 Protein

8. Evaluation of fever in the international traveler  Did they get pre-travel advice?  Did they follow the advice?  Where did they travel and how?  When did they get sick – before they returned home or several weeks later?

9. Incubation periods  <10 days – Dengue, Traveler’s diarrhea, Yellow fever, Spotted fevers.  10-21 days – typhoid fever Leptospirosis, Malaria, Typhus Viral hemorrhagic fevers.  >21 days – Acute HIV infection, Amebic liver abscess, Malaria, Tuberculosis and all viral hepatitis.

10. Most Common  Malaria is the most common cause of fever in the traveler returning from the tropics. 27%-42%  Dengue 8%  Hepatitis 6%  Enteric fever 3%

11. Visiting Friends and Relatives ( VFR’s)  Huge problem and the rate of infection is increasing  Reason – They do not take the prophylaxis.  500 million infections, 1 million deaths  They feel like they are immune from the diseases they grew up with.

12. Who gets Travelers malaria?  VFR’s 23%  Tourist 12%  Business 9%  Missionary 11%  Peace Corps 2%

13. Malaria Deaths  1992-2001 4685 malaria cases in US citizens  19% took inappropriate. Drug  56% took nothing  In the US about 6 deaths a year

14. Clinical presentation  Fever and influenza symptoms  These symptoms occur at intervals.  Some have anemia and jaundice ( think hepatitis)  Some have diarrhea ( think travelers diarrhea)  As early as 6 days, or months later.

15. Malaria  Four types – falciparum, vivax, ovale, and malariae.  Anopheles mosquito  P. falciparum –the worst – seizures, mental confusion, kidney failure and coma.  Transmission at dawn and dust.

16. Chemoprophylaxis  When and where are they at risk for exposure?  What type of malaria is there?  More resistance to falciparum is being reported – Thailand, Burma, and Cambodia

17. Drugs  For Chloroquine sensitive areas  Chloroquine 500 mg tab, once a week starting one week prior and continuing four weeks after.  May exacerbate psoriases

18. Chloroquine resistant  Mefloquine (Lariam)  Falling out of favor  Contraindications – Psych anything, Epilepsy – decreases seizure threshold, Cardiac conduction defects  250 mg each week

19. More Drugs  Doxycycline – Low cost but DAILY dosing.  Adverse effects – GI upset, vaginal candidasis, photosensitivity

20. The New Kid on the block  Malarone – atovaquone 250mg, + proguanil 100 mg.  FDA approved July 2000  Contraindicated with renal impairment  Take DAILY  EXPENSIVE

21. How to prevent failure  My patient had seeked advice – often with VFR’s this does not happen  Cost and drug interaction was a problem  Patient still travels to Nigeria and only treats herself if she becomes ill.  She has now been hospitalized twice for Malaria.

22. Conclusion  Talk to patients about travel during the physicals or other visits as appropriate.  Review vaccinations – compare Hep A and Hep B to the combined shot.  Modes of travel can be the most dangerous part of the trip.

23. Dr. Stanford’s Bottom line  If I had 90 seconds and the traveler possessed only limited funds, I would address : Malaria, Hepatitis A, Seatbelts, And condoms.

24. Bibliography  Lo Re, VL and Gluckman SJ. “Travel Immunizations.” Am Fam Physician 2004;70(1):89-99, 103-4.  Blair JE. “Evaluation of Fever in the International Traveler.” Postgrad Med, 2004;116(1):13-29.  “The Malaria Controversy.” Prescribers Letter Detail Document 181006.  Centers for Disease Control and Prevention. Health Information for the International Traveler 2001-2002. Atlanta: US Department of Health and Human Services, Public Health Service, 2001.

25. Internet Sites  www.malaria.org www.malaria.org  www.tripprep.com www.tripprep.com  www.cdc.gov www.cdc.gov  www.istm.org www.istm.org