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Traveler with a fever. Case presentation Ann Schmidt. CASE. 68 yo woman presented to the ER with several day history of fever and one day history of confusion. Past Medical History. NIDDM for several years, well controlled Coronary heart disease with bypass grafting x 3 one year ago

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traveler with a fever

Traveler with a fever

Case presentation

Ann Schmidt

slide2
CASE
  • 68 yo woman presented to the ER with several day history of fever and one day history of confusion.
past medical history
Past Medical History
  • NIDDM for several years, well controlled
  • Coronary heart disease with bypass grafting x 3 one year ago
  • Mild Hypertension
social history
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.
family history
Family History
  • Positive for heart disease and diabetes.
  • No breast or colon cancer
  • Family members in the US are healthy.
review of systems
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.
er evaluation
ER evaluation
  • Labs – Normal CBC, glucose, electrolytes and BUN/Creatinine.
  • Head CT – normal
  • Chest X-ray – normal
  • Urinalysis – trace ketones, + 2 Protein
evaluation of fever in the international traveler
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?
incubation periods
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.
most common
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%
visiting friends and relatives vfr s
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.
who gets travelers malaria
Who gets Travelers malaria?
  • VFR’s 23%
  • Tourist 12%
  • Business 9%
  • Missionary 11%
  • Peace Corps 2%
malaria deaths
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
clinical presentation
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.
malaria
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.
chemoprophylaxis
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
drugs
Drugs
  • For Chloroquine sensitive areas
    • Chloroquine 500 mg tab, once a week starting one week prior and continuing four weeks after.
    • May exacerbate psoriases
chloroquine resistant
Chloroquine resistant
  • Mefloquine (Lariam)
    • Falling out of favor
    • Contraindications – Psych anything, Epilepsy – decreases seizure threshold, Cardiac conduction defects
    • 250 mg each week
more drugs
More Drugs
  • Doxycycline – Low cost but DAILY dosing.
  • Adverse effects – GI upset, vaginal candidasis, photosensitivity
the new kid on the block
The New Kid on the block
  • Malarone – atovaquone 250mg, + proguanil 100 mg.
  • FDA approved July 2000
  • Contraindicated with renal impairment
  • Take DAILY
  • EXPENSIVE
how to prevent failure
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.
conclusion
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.
dr stanford s bottom line
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.

bibliography
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.
internet sites
Internet Sites
  • www.malaria.org
  • www.tripprep.com
  • www.cdc.gov
  • www.istm.org