Fever in travellers (25-6-14)

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This talk on "Fevers in Travellers" focusses history taking skills, diagnosis and treatment of Malaria and some other tropical disease that we may on rare occasions encounter in the urban ED environment of New South Wales. I would like to thank Dr Julian Chow, and his sources, for sharing this comprehensive talk on the topic, which was presented as part of the Wollongong Emergency Medicine registrar teaching program. We would welcome comments and further contributions on this topic.

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  • Normal haemoglobin levels, mild microcytosis and hypochromic
    Mild thrombocytosis
    Slightly dry with a urea of 7.4
    Mildly deranged LFT
  • Predominantly those living in Sub Saharan Africa where healthcare is poorly accessible.
    Widely pandemic in the Americas, South and South East Asian countries and to some extent part of Europe.
    207 million cases of malaria in 2012, 42% mortality rates in Africa
    In Africa where a child dies every minute from malaria
  • Three main stages, human liver stage, human blood stage and the mosquito stage
    During a blood meal, mosquito inoculates sporozoites into human host
    These then infect hepatocytes
    Which mature to schizonts
    The rupture of schizonts into blood stream
    Infects red blood cells
    May either mature to form more Schizonts which further ruptures to spread the infection
    Or mature to male or female Gametocytes
    Anopheles mosquito strikes back, ingests the Gametocytes which multiplies within the mosquito’s stomach
    Eventually, spreads to the salivary glands of the mosquito
  • In pandemic areas, undiagnosed fever is malaria until proven otherwise. Can lead to resistance
  • To rule out malaria, at least 3 slides need to be negative. Must be taken 12-24 hours apart
  • Fever in travellers (25-6-14)

    1. 1. Dr Julian Chow Registrar Teaching at M&M Meeting Wollongong Hospital Emergency Department 25th June 2014
    2. 2.  Case study  Malaria overview  Fever in travellers from an Emergency Department perspective
    3. 3.  36 y/o gentleman  PC:- Fevers with recent travel  Background:- ◦ Recently returned from Benin and Togo ◦ Generally fit and well, nil regular medications
    4. 4.  Returned from travels 2 weeks ago ◦ 1/52 h/o intermittent fevers, nocturnal diaphoresis, myalgias, arthralgias, bilateral frontal headache, nausea, anorexia and weight loss of 2 kg ◦ Symptoms worsened over the last 2/7  Referred by GP to I.D. via Emergency Department ◦ Positive thick and thin blood films and antigen test for P. Falciparum ◦ HIV negative ◦ Syphilis negative  Social history ◦ 2010 – Migrated from Togo to Australia ◦ 3 months travelling in Benin and Togo, West Africa to see family ◦ No h/o unwell whilst there. No precautions or chemoprophylaxis taken ◦ Mainly stayed with family in metropolitan area, no new sexual contacts / tattoos / blood transfusion / hospitalisation ◦ Currently unemployed, single and lives with local Australian housemates
    5. 5.  BP 124/76, 97 bpm, RR 20, 96% RA, 37.0C  Looks well, not in discomfort ◦ Examination fairly unremarkable ◦ Spleen edge ◦ No rashes or visible bites
    6. 6.  ECG sinus rhythm  Urine analysis – NAD  Hb 151, WCC 5, Plat 98, MCV 72.7, MCH 26  UEC Ur 7.4, rest NAD  GGT 124, ALT 50  CXR - NAD
    7. 7.  Admitted Dr. Adams, Infectious Diseases ◦ Artemether 80 mg + Lumefantrine 480 mg PO BD ◦ Artemisinin-based Combination Therapy (ACT) ◦ Continue for next 3/7  Repeated bloods 1/7 after admission – similar ◦ Discharged home ◦ Follow up 1/52 with ID  Bloods 1/52 after ◦ Thrombocytopenia resolved to 268 ◦ LFT still remained deranged
    8. 8. Global Pandemic
    9. 9.  Affects up to 3 billion people worldwide  Half the world’s population at risk
    10. 10.  Malaria caused by Plasmodium Parasites ◦ Plasmodium falciparum (most common & lethal) ◦ Plasmodium vivax ◦ Plasmodium malariae ◦ Plasmodium ovale  Transmitted vector exclusively Anopheles ◦ Feeds at night, after monsoons ◦ Exclusively female mosquitoes ◦ Usually human hosts
    11. 11.  Should be suspected if history of fever  Recently visited malaria endemic area regardless of adherence to prophylaxis  Incubation period ◦ Minimum is 6 days ◦ Falciparum in first month, all within <6 months ◦ Vivax or Ovale present later 6 months to few years
    12. 12.  Physical examination – often unremarkable  Recurrent cyclical fever and sweating ◦ Every 36 hours / tertian fever / quartan fever  Children more likely with signs ◦ Hepatomegaly, splenomegaly, somnolence  Severely ill patients ◦ Jaundice, confusion, seizures
    13. 13.  Routine assessment ◦ FBC, U&E, LFT, blood glucose  Unwell patients ◦ Blood gases, cultures, lactate, coagulation profile ◦ Urine analysis, stool MCS, CXR ◦ Lumbar puncture – febrile with impaired GCS or seizures
    14. 14.  Blood smear + microscopy (EDTA tube) ◦ Thick slides – evaluation of parasitic count (>2% RBC is severe) ◦ Thin slides – evaluation of type of malaria  Rapid diagnostic test (RDT) ◦ Capillary blood onto test strip, qualitative test only
    15. 15.  Impaired consciousness or seizures  Renal impairment  Acidosis  Hypoglycaemia  Acute respiratory distress syndrome  Haemoglobin <8 g/dL  Spontaneous bleeding / DIC  Shock  Haemoglobinuria (without G6PD)
    16. 16.  Safety of outpatient treatment  Children with Falciparum should be admitted for 24 hours  Consider admission for pregnant women, infants and elderly as deteriorate rapidly  All patients to be discussed with specialist
    17. 17.  Dependent on origins and parasite subtype  Uncomplicated P. Falciparum (PO) ◦ Artemisinin-based Combination Therapy (ACT)  Artemether + Lumefantrine ◦ Atovaquone + Proguanil ◦ Quinine Sulphate + Doxycycline / Clindamycin  Severe malaria (IV) ◦ Artesunate or Quinine Dihydrochloride  Other malaria ◦ ACT or Mefloquine
    18. 18.  Vector avoidance  Chemoprophylaxis ◦ Not always effective, advise if symptoms develop to see medical professional ◦ Dependent on areas visiting  Chloroquine susceptible/resistant areas  Mefloquine resistant areas
    19. 19. From an Emergency Medicine Perspective
    20. 20. QUESTIONS EXAMPLES Country of origin and country of travel Latent disease, possible exposures Occupation, hobbies, activities Farmer, abattoir worker, cave explorer, swimming Prophylaxis Immunisations, malaria prophylaxis, insect repellents Treatments or procedures Blood transfusions, injections, splenectomy, gastrectomy, tattoos Drugs Prescribed, over-the-counter, illicit Diet Seafood, raw food, traditional or homemade food Sex Unprotected sex, HIV partner, multiple partners, commercial sex Allergies Antibiotics, food, insect bites, plant Pets Birds, dogs, cats, other Family history Diabetes, sickle-cell anaemia, tuberculosis Bites Insects, snake, animal, spider, human
    21. 21. * Evaluation should also include the differential diagnoses that would be considered in a non-traveller with fever † Travel to high-risk area, rural or prolonged travel, non-compliance with prophylaxis
    22. 22.  Full septic screen, LFT + thick & thin slides  Reverse barrier nursing + isolated room  Negative pressure rooms if aerosol infection (SARS)  Ensure staff are vaccinated and minimise number of staff in contact with patient  Public health department to be contacted  SEEK EXPERT ADVISE
    23. 23.  Haemorrhage (or bruising)  Neurologic impairment (mental status or paralysis)  Acute respiratory distress  Skin changes (rashes or jaundice)
    24. 24.  Both Aedes mosquito borne viral infection ◦ Similar Sx - Fever, malaise, N&V, headache, myalgia ◦ Southern Asia, western Pacific, central Africa, South America ◦ Virology or antibodies in serum  Dengue ◦ Incubation period 4-7 days ◦ Bone pain (“break bone fever”) ◦ Transient macular rash, petechia, lymphadenopathy, hepatomegaly ◦ Reduced WCC and platelets, deranged LFT ◦ Recover after 3-7 days with symptomatic Rx ◦ Dengue shock syndrome (DSS) – ↓plasma protein, hypotension, pleural effusions, ascites, bleeding. Mx supportive and fluid +/-  Chikungunya ◦ Rarely fatal. Joint pain may persist for several months ◦ Mainstay of Rx is symptomatic management
    25. 25.  Salmonella typhi and S. Paratyphi ◦ Faeco-oral transmission route ◦ Incubation period 7-14 days  Malaise, fever, dry cough, abdo discomfort, constipation/diarrhoea, splenomegaly, confusion or hallucinations  Rose spots – pink macular spot  Ix – mild anaemia, WCC normal  Mx – Isolate, barrier nursing, ID admission, Ciprofloxacin or Cefotaxime
    26. 26.  Key in history  Isolation + sepsis pathway  Tropical medicine is a vast specialty  Seek specialist advise from Infectious Diseases in all travellers with fevers
    27. 27.  http://www.who.int/malaria/media/world_ma laria_report_2013/en/  http://www.nhs.uk/Conditions/malaria/Page s/Introduction.aspx  http://www.cdc.gov/malaria/  UK Malaria Treatment Guidelines, Lallo et al, Journal of Infection 2007  http://en.wikipedia.org/wiki/Malaria  eTG guidelines  Oxford Handbook Emergency Medicine  http://www.australianprescriber.com/magazi ne/35/1/10/4

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