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Fever and Diarrhea in the Returned Traveler. Dr. Chris Greenaway Division of Infectious Diseases , SMBD- Jewish General Hospital Consultant, McGill Center for Tropical Diseases. Case #1. 46 year old Kenyan female presents to your office with a 4 day history of high fever 40C and cough - PowerPoint PPT Presentation
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Fever and Diarrhea in the Returned Traveler
Dr. Chris GreenawayDivision of Infectious Diseases, SMBD- Jewish General Hospital
Consultant, McGill Center for Tropical Diseases
• 46 year old Kenyan female presents to your office with a 4 day history of high fever 40C and cough
• 13 year old son has had a similar illness for 6 days
• Physical exam is normal
• What do you want to know?
• What investigations do you want to do?
Case #1
Case #1
• Seen in a walk-in clinic
• CXR- normal
• Given 2nd gen cephlosporin
• Sent home
What do you want to know?
1. Travel history and itinerary
2. Exposure history
3. Pre-travel preparation
1. Travel itinerary
• countries• duration• urban vs. rural• accommodation • exact
arrival/departure dates
Incubation periods for selected tropical diseases
Short: < 10 days bacterial enteritistyphoiddengueMarburg/EbolaSARSOther viralRickettsia- typhus, other
Incubation periods (Cont’d.)
Intermediate (10 - 21 days)
malaria brucellosistyphus leptospirosisQ fever trypanosomiasistyphoid fever Lassa fever
Incubation periods (Cont’d.)
Long: > 21 days
viral hepatitis Malariatuberculosis schistosomiasis HIVAmoebic Liver AbscessAfrican trypanosomiasisVisceral leishmaniasis
2. Exposure history
Activity:Raw,undercooked food
Untreated water/milk
Fresh water exposure
Disease risk:
• hepatitis, enteritis
• Enteritis, brucellosis
• schistosomiasis, leptospirosis
Exposure history (Cont’d.)
Activity:
• sexual contact
• Sexual contact
tattooing, piercing
Disease risk:
• syphilis, GC, chlamydia
• HIV, hepatitis B,
Hepatitis C
3. Pre-Travel Preparation
i. Immunizations: efficacy:• yellow fever > 95%
• hepatitis A > 95%
• hepatitis B 80-95%
• typhoid fever 70%
• meningococcal meningitis > 90%
• Japanese encephalitis > 90%
Pre-Travel Preparation (Cont’d)
ii. malaria chemoprophylaxis:• drug • dose• compliance • duration iii. other medications
Case #1
• 3 days later she is brought to ER at the JGH with confusion and high fever. Has been ill for 7 days
Initial Lab resultsABG: pH: 7.0, pCO2:32, HCO3: 8, pO2: 539
WBC: 6.3 , Hb: 152, Plts: 17(59% PMNs, 9% Immature, 22% lymphs)
Cr: 681, BUN: 51, Lactate: 11Bili 211/131, ALT:54, Alk Phos: 51, GGT: 24, LDH: 931
What is your diagnosis?
Case #1
• Lab did a malaria smear because of severe thrombocytopenia
P. falciparum: 15% parasitemia
• Fever began, 1 week after returning from trip to Kenya, South Africa and Uganda.
Case #1
• Died 3 hours later from severe falciparium malaria just as IV Quinine was started
Case #1
EBI KIMANANI• Born in a small village in Kenya,
1 of 11 children• PhD Biostatistician • Active advocate in the fight against
diseases that ravaged Africa.• Travelled extensively to Africa
setting up research protocols for new drugs to treat Malaria and HIV.
• Married with 3 sons (10, 13, 15 yrs)
Travelers Immigrants
malaria, malaria, malaria prolonged fever
TB, TB, TB
Fever from the Tropics (percent)
MacLean
(N=587)
Doherty
(N=195)
O’Brien
(N=232)Malaria 32 42 27Resp Tract 11 2.5 24Diarrhea 4.5 6.6 14Hepatitis 6 3 3Dengue 2 6 8UTI 4 2.5 2Enteric Fever 2 2 3TB 1 1 0.4Unknown 25 24.5 9
Spectrum of Disease by Region of Origin in
Ill Travellers- GeoSentinel Caribbean Central
AmericaSouth
America
Sub-Saharan Africa
South Asia SE Asia
Diarrhea
Acute/chronic
Diarrhea
Acute/chronic
Parasitic
Diarrhea
Acute/chronic
Parasitic
Malaria Diarrhea Diarrhea
Larva migrans Larva migrans Leishmania Diarrhea
Acute, chronic, parasitic
Dengue Dengue
Dengue Myiasis Larva migrans Schistosomiasis Enteric Fever Larva migrans
Dengue Myiasis Filaria Malaria Malaria
Malaria Dengue Rickettsia
Freedman NEJM 2006;354:119-130
Fever from the tropics is often not tropical
...but is still malaria until proven otherwise
Investigations of the Returned Traveller with Fever
ON ALL PATIENTS
• MALARIA smear
If suspect rpt Q12 X3
• CBC
• Cr, BUN
• LFTs
• Blood C&S
• U/A
• Urine C&S
OTHER
Depends on focal symptoms
ie CXR
Serology
Stool C&S
Other imaging
Etc
Case #2
• 38 year old male with a 4 day history of fever and chills beginning 1 week after returning from a 1 month trip visiting family in India
• The physical exam shows a moderately toxic male with a temperature of 39, Pulse of 90 and LLQ tenderness on palpation, spleen tip palpable
• No rash, no lymphadenopathy
Case #2
Labs
Hb 115, WBC 6.0 , Plts 110
LFTs Bili normal, ALT- 302, AST-336,
Normal Alk Phos, LDH 997
Cr/BUN- normal
Case #2Differential Diagnosis
• Malaria, malaria, malaria
• Typhoid Fever
• Leptospirosis
• Endocarditis
• Pyelonephritis
• Hepatititis- A, E, C, B
Blood cultures – positive for Salmonella typhi
Malaria Smear - Negative
Typhoid Fever- Epidemiology
Highest Risk Countries (0.3/1000 travelers/month)• Indian Subcontinent• SE Asia• Central America- Mexico• Western South America – Peru• Parts of North and West Africa• Middle East
Typhoid fever: Clinical
• IP: 3-60 days (7-14 d)
• Prolonged fever (99), anorexia (85), headache(85), abdominal pain (50)
• constipation (40), diarrhea (45), cough (35), sore throat (20)
• apathy (70), hepatomegaly (50), splenomegaly (35), rose spots (0-50), relative bradycardia (15)
Typhoid fever: Complications
Clinical:• intestinal perforation 3% • intestinal hemorrhage 15% • neuropsychiatric: delirium, stupor, coma• myocarditis 1-5%Relapse: <5% (2-4 wks); fatality <1%Chronic carriage: 30% x 1 mo; 10% x 3 mo;
3% x 1 yr
Typhoid fever: Diagnosis
• general: anemia, N WBC, platelets, relative lymphocytosis, AST, ALT
• blood culture: 40-80%
• bone marrow culture 80-95%
• internal secretions: 60-80% (aspiration)
• stool culture (wk.2) 50%, urine culture 5-10%
• rose spots: 60%
Case #3
• 28 year old female with a 3 day history of fever, headache and photophobia and a 1 day history of arthritis of her knees, wrists and hands and a truncal rash.
• She had just return 2 days prior from a 3 week trip to Mauritius.
• What else do you want to know?
• What tests do you want to do?
Case #3
Labs
• WBC 2.8, lymphopenia, monocytosis, Hb- 115, Platelets- 100
• PT/PTT- normal
• Cr/BUN- normal
• LFTs- normal
Malaria smear- Negative
Blood cultures- Negative
Differential Dx
• Fever
• Short incubation period
• Arthritis
• Rash
• Negative malaria smear
• Chickungunya
• Dengue
• Parvovirus
• Rubella
• Leptospirosis
• Rickettsia- typhus
Chikungunya• Outbreak in 2005 in Islands of the Indian Ocean (Reunion,
Mauritius) and India, Sri Lanka
• Arbovirus transmitted by mosquitos
• Arthralgias (100%), myalgias (97%), headache (84%),
diffuse MP rash (77%), lymphadenopathy (41).
• 1/3 may have arthralgias up to 1 month (occas months)
• Fever duration ~4 days
• Incubation 4-7 days
• Lymphopenia (67%), thrombocytopenia (50%), increase ALT/AST (67%)
• Dx with serology
Dengue Fever: Clinical• short incubation period: 2-7 d. (max. 10)
• classical dengue:
-fever -retroorbital pain -rash
-headache -myalgia/bone pain (45%)• saddle back fever (2-7 d, afeb 1-2 d, recurrence)
• rash day 3-5; maculopapular, diffuse erythema
• atypical presentation common
• short duration: < 1 week
Dengue: diagnosis
• leukopenia, thrombocytopenia
• Mild to mod increase LFTs, LDH
• dengue IgM positive
• 4 fold rise in dengue IgG antibodies
Case #4
• 35 year old female with a 2 day history of diarrhea tinged with blood, 1 day history of chills and fever
• She had just return 1 days prior from a 2 week trip to Mexico
• What tests would you like to do?
• What is the most likely diagnosis?
Case #4
Tests
•Stools C&S
•Stools C.difficile (if had received prior AB)
•Malaria smear
•If toxic Blood cultures, CBC, Cr, LFTs
DDx
Shigella, Salmonella, Camphylobacter,
E.Coli 0157, E. histolytica
DIARRHEA IN THE RETURNED TRAVELLER
Boil it, cook it, peel it, or forget it!
Easy to remember… ...Impossible to do !
Lawrence Green,1995
Traveller’s Diarrhea
• Is the most common travel-related health problem
• Occurs in 25-50% of international travellers
Traveller’s Diarrhea
Clinical• IP- 1-2 days• 1/3 onset in 1st 2
wks.• 4-5 loose stools
over 4-5 days (85%)
• fever 10% • bloody stool 15%
Sequelae• 40% modify activities• 20% confined to bed• 1% hospitalized• 8-15% diarrhea > 1
wk• 2% persistent diarrhea
> 1 mo.
Etiology (Varies by country)
Bacteria 50 – 75 % Protozoa 0 – 5 % Viruses 0 – 20 % Unknown 10 – 40 %
• ETEC 20-25%• Shigella 12-14%• Campy 5-9%• Salmonella 3-
5%• Rotavirus
8%• Giardia 1-12%• E. Histo 5%• Crypto 5% • Cylospora
11%
Treatment
• Uncomplicated TD is self-limited and responds well to symptomatic treatment
Management determined by
• Severity of disease
• Age
• Underlying conditions
• Pathogen isolated (eventually)
Treatment – Uncomplicated TD
• Symptomatic
• +/- Empiric Antibiotic Treatment
Quinolone 3 days
Azithromycin 3 days
(esp SE Asia/ India Sub-Continent)
Rifaximin 3 days
Treatment- Complicated TD
Antibiotics
• High fever >2 days
• Bloody, Mucoid diarrhea
Hydration if:
• Profuse watery diarrhea
• Severe vomiting
Case #5
52 year old male
RC: Chronic diarrhea x 2 months
Travel: Asia 6 months- Sept 7, 2010-March 8, 2011
Australia (7wks), Indonesia (8wks), India (8wks), Australia (1 wk). Arrived in Cdn 1 wk prior
Past Hx: Depression, Gastric reflux
Meds: Prosac, Trazadone, Losec
Case #5HPI: 2 month history of non-bloody diarrhea (3-4 stools/day) that began a fews wks after arrriving in India, associated with cramps and ++flatulence, and 22 lb wt loss
-1 wk prior to seen in clinic treated with a 7 day course of Flagyl 500 mg TID without a change in symptoms.
Additional Hx:
Gay, engaged in oral penile, peri-anal sex, no anal intercourse while in India, HIV – 2 yrs prev
Case #5
• CBC- normal
• LFTs, Cr- normal
• Stools O & P- pending
Stools O & P- Cryptosporidium 1+
DDx: Resistant Giardia, E. Histolytica, Cryptosporidium, Lactose deficiency, post-infectious IBD, Unmasked IBD
Persistent TD
• Definition: diarrhea > 30 d
• Swiss 0.9%• Peace Corps 1.7%• Tour group 2.9%
Dupont, Clin Infect Dis 1996;22:124-8
Taylor, Med Clin N Am 1999;83:1033-51
Persistent TD Etiology
1. Infection (Giardiasis, C. difficile)
2. Post-infective (IBS, lactose intolerance)
3. Malabsorption (Tropical sprue)
4. Umasking GI (IBD, Coeliac)
5. Idiopathic (Brainerd)
6. Non-tropical (IBD)
Persistent Travellers’ diarrhea
Post infectious IBS 70
Lactose intolerance 15
Infectious (giardiasis, C. diff.) 10
IBD <1
Sprue:tropical or coeliac <1
Keystone JS - personal communication 2001
Approach to persistent T.D.
Exclusion of enteric pathogens
Strict lactose-free diet x 5 d.
High fibre (psyllium; metamucil) +/- MOM, lactulose
Cholestyramine (Questran)