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Fever and Diarrhea in the Returned Traveler

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

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Fever and Diarrhea in the Returned Traveler

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  1. Fever and Diarrhea in the Returned Traveler Dr. Chris Greenaway Division of InfectiousDiseases, SMBD- Jewish General Hospital Consultant, McGill Center for Tropical Diseases

  2. Case #1 • 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?

  3. Case #1 • Seen in a walk-in clinic • CXR- normal • Given 2nd gen cephlosporin • Sent home

  4. What do you want to know? • Travel history and itinerary • Exposure history • Pre-travel preparation

  5. 1. Travel itinerary • countries • duration • urban vs. rural • accommodation • exact arrival/departure dates

  6. Incubation periods for selected tropical diseases Short: < 10 days bacterial enteritis typhoid dengue Marburg/Ebola SARS Other viral Rickettsia- typhus, other

  7. Incubation periods (Cont’d.) Intermediate (10 - 21 days) malaria brucellosis typhus leptospirosis Q fever trypanosomiasis typhoid fever Lassa fever

  8. Incubation periods(Cont’d.) Long: > 21 days viral hepatitis Malaria tuberculosis schistosomiasis HIV Amoebic Liver Abscess African trypanosomiasis Visceral leishmaniasis

  9. 2. Exposure history Activity: Raw,undercooked food Untreated water/milk Fresh water exposure Disease risk: • hepatitis, enteritis • Enteritis, brucellosis • schistosomiasis, leptospirosis

  10. Exposure history (Cont’d.) Activity: • sexual contact • Sexual contact tattooing, piercing Disease risk: • syphilis, GC, chlamydia • HIV, hepatitis B, Hepatitis C

  11. 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%

  12. Pre-Travel Preparation (Cont’d) ii. malaria chemoprophylaxis: • drug • dose • compliance • duration iii. other medications

  13. 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 results ABG: 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: 11 Bili 211/131, ALT:54, Alk Phos: 51, GGT: 24, LDH: 931 What is your diagnosis?

  14. 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.

  15. Case #1 • Died 3 hours later from severe falciparium malaria just as IV Quinine was started

  16. 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)

  17. Travelers Immigrants malaria, malaria, malaria prolonged fever TB, TB, TB

  18. Fever from the Tropics(percent)

  19. Spectrum of Disease by Region of Origin in Ill Travellers- GeoSentinel Freedman NEJM 2006;354:119-130

  20. Fever from the tropics is often not tropical ...but is still malaria until proven otherwise

  21. 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 Investigations of the Returned Traveller with Fever

  22. 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

  23. 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

  24. Case #2 Differential Diagnosis • Malaria, malaria, malaria • Typhoid Fever • Leptospirosis • Endocarditis • Pyelonephritis • Hepatititis- A, E, C, B Malaria Smear - Negative Blood cultures – positive for Salmonella typhi

  25. 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

  26. 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)

  27. 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

  28. 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%

  29. 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?

  30. 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

  31. Differential Dx • Fever • Short incubation period • Arthritis • Rash • Negative malaria smear • Chickungunya • Dengue • Parvovirus • Rubella • Leptospirosis • Rickettsia- typhus

  32. 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

  33. 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

  34. Dengue: diagnosis • leukopenia, thrombocytopenia • Mild to mod increase LFTs, LDH • dengue IgM positive • 4 fold rise in dengue IgG antibodies

  35. 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?

  36. 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

  37. DIARRHEA IN THE RETURNED TRAVELLER

  38. Boil it, cook it, peel it, or forget it! Easy to remember… ...Impossible to do ! Lawrence Green,1995

  39. Traveller’s Diarrhea • Is the most common travel-related health problem • Occurs in 25-50% of international travellers

  40. 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. Traveller’s Diarrhea

  41. 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% Etiology (Varies by country)

  42. Treatment • Uncomplicated TD is self-limited and responds well to symptomatic treatment Management determined by • Severity of disease • Age • Underlying conditions • Pathogen isolated (eventually)

  43. Treatment – Uncomplicated TD • Symptomatic • +/- Empiric Antibiotic Treatment Quinolone 3 days Azithromycin 3 days (esp SE Asia/ India Sub-Continent) Rifaximin 3 days

  44. Treatment- Complicated TD Antibiotics • High fever >2 days • Bloody, Mucoid diarrhea Hydration if: • Profuse watery diarrhea • Severe vomiting

  45. 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

  46. Case #5 HPI: 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

  47. Case #5 • CBC- normal • LFTs, Cr- normal • Stools O & P- pending DDx: Resistant Giardia, E. Histolytica, Cryptosporidium, Lactose deficiency, post-infectious IBD, Unmasked IBD Stools O & P- Cryptosporidium 1+

  48. 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

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