Managing the Returning Traveler
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1 Managing the Returning Traveler Kris Paolino, MD Infectious Disease Staff February 2015 UNCLASSIFIED
2 Thank You to: COL Stephen Thomas CAPT (Ret) Philip Coyne LTC James Moon UNCLASSIFIED Slide 2
3 Disclaimer The views expressed in this presentation are those of the speaker and do not reflect the official policy of the Department of Army, Department of Defense, or U.S. Government No financial relationships to disclose UNCLASSIFIED Slide 3
4 Outline BLUF Soliciting a detailed medical history Infectious diseases of returning travelers Infectious disease emergencies Medical history informing diagnosis UNCLASSIFIED Slide 4
5 BLUF: Caring for the Infectious Disease Patient A comprehensive, in-depth medical history is your best diagnostic tool Geographic and ID threat situational awareness Know your ID emergencies Know what you don t know, seek assistance when needed Many of the same questions you ask in PREPARATION of the traveler will be things you ask them when they return UNCLASSIFIED Slide 5
6 Common Things are Common Not this Usually this Slide courtesy of Capt (Ret) Coyne UNCLASSIFIED Slide 6
7 Soliciting a Detailed Medical History UNCLASSIFIED Slide 7
8 Chief Complaint Localizing Focal lesion (cellulitis, MRSA abscess) Bite (arthropod, animal, human) Post-traumatic (altercation, vegetation) Anatomical (CNS, GU, GI, etc.) Generalized and systemic Fever, chills, rigors Muscle and / or joint pain Fatigue UNCLASSIFIED Slide 8
9 Chief Complaint: My finger looks like a blood sausage Cat bites causing skin /soft tissue infections Slide courtesy of COL Thomas UNCLASSIFIED Slide 9
10 History of Present Illness Key information Detailed chronology of illness Patient was well until DATE when X happened Appearance / disappearance of signs / symptoms Non-specific illnesses may declare themselves Identify patterns if they exist Example: patterns of fever (every 3 days) Incorporate important medical background of patient Age (impacts presentation, fever curves, etc.) Immunodeficient (HIV, medications, malignancy) UNCLASSIFIED Slide 10
11 Elderly WM with eye infection -Antibiotic history revealed poor Pseudomonas coverage -Infection progressed patient lost eye Slide courtesy of COL Thomas UNCLASSIFIED Slide 11
12 History of Present Illness Key information Incorporate activities / exposures Animals, arthropods, people, vegetation Urban, rural environment exposure Indoor or outdoor activities Incorporate relevant active (recent) medications Prophylaxis, immunomodulators, OTC medications Incorporate relevant associated travel history UNCLASSIFIED Slide 12
13 AAF started on steroids for presumed sarcoid a month after leaving Ft. Irwin, develops bone pain, SOB, fever, and skin nodules - MRI of knee joint demonstrates Coccidoidomycosis lesion Picture courtesy of COL Thomas UNCLASSIFIED Slide 13
14 Review of Systems Pertinent positives and negatives Specifically mention if AFEBRILE CNS: evidence of meningitis, encephalitis, any neuro Respiratory: tracheobronchitis, pneumonia Oropharynx: pharyngitis, bleeding gums, poor dentition GI: diarrhea with blood, mucus, rice water appearance GU: discharge, dysuria, abnormal menses Skin: rash, location, itching, character Extremities: localized pain, joint versus bone pain UNCLASSIFIED Slide 14
15 Past Medical/Surgical History Drill down on relevant pre-existing medical conditions Immunosuppressive conditions Drill down on chronic or re-occurring conditions Examples: frequent respiratory infections, meningitis Presence or absence of organs Appendix, gallbladder, spleen, thymus Previous surgical interventions Heart surgery (valve) Implant of any hardware or foreign material (bacteria LIKE metal) Known lab / radiologic abnormalities Examples: lung nodule/ca++, heart block, etc. UNCLASSIFIED Slide 15
16 Medications / Immunizations Prescribed and Over-the-counter meds (previous antibiotics?) Immunosuppressives Examples prednisone, DMARDs Anti-pyretics (ASA, NSAIDS, acetaminophen) Manipulate fever curve Prophylaxis (detailed account, missed doses) Test understanding (especially malaria prophylaxis) Anything which could impact absorption or metabolism of chronic or prophylactic medications impacting their performance. All routine and travel specific vaccinations! UNCLASSIFIED Slide 19
17 AAM with sarcoid, treated with steroids -Headache and visual disturbance -Lumbar puncture performed -CSF Gram s strain demonstrates Cryptococcus neoformans India ink Silver stain Gram stain Cryptococcus meningitis Principles and Practice of Infectious Diseases, 8 th ed UNCLASSIFIED Slide 20
18 22 year old USMC E-3 29 Aug: Presents to sick call on ship with one day of fevers and diarrhea deployed to AFRICOM Watery stools, no blood or abdominal pain Temp 101.4, 130/92, p 72 exam normal; dx with viral gastroenteritis, given tylenol and SIQ 24 h Notes indicate he recently ate sugar cane but nothing else 01 Sep: Feels better, afebrile 02 Sep: Diarrhea returns, vomiting, feels light headed Temp 104.1, pulse bpm, tilt positive. Dx with viral syndrome, given IV fluid and started on ciprofloxacin UNCLASSIFIED Slide 21
19 22 year old USMC E-3 04 Sep: Unable to keep down fluids Afebrile, BP 94/63, p 109 No assessment in chart, never seen by physician Trimethobenzamide IM, return if symptoms worsen 05 Sep: Falls out of his rack and hits head while trying to get to the bathroom Temp 102.2, P 111, 90/39 Admitted to ship s medical hold for diarrhea/dehydration WBC 11.8, HGB 10.1, Platelets 42, ALT 114, creat 1.4 Doxycycline added to ciprofloxacin for unclear reasons Multiple other Marines start presenting with diarrhea and fevers UNCLASSIFIED Slide 22
20 NOT NORMAL UNCLASSIFIED Slide 23
21 22 year old USMC E-3 07 Sep Patients arrives at NNMC with Cerebral malaria 17% parasitemia with Plasmodium falciparum Intubated for 9 days, requires 3 pressor support Death imminent board, gets CRBSI with Acinetobacter - JAMA 1967;199:141 Vietnam - US Soldiers with Malaria Diarrhea in 38% - JAMA 1994;272:398 Somalia - US Marines with Malaria Diarrhea in 38% - Am J Trop Med Hyg 2010; 83(2): 258 Liberia - US Marines with Malaria Diarrhea in 62% UNCLASSIFIED Slide 24
22 Liberia 01 Aug 15 Aug 30 Aug 15 Sep Washington Post, September 2003 UNCLASSIFIED Slide 25
23 Warehouse that Housed Marines at Roberts International Airport, Liberia, during August 2003 peacekeeping deployment UNCLASSIFIED Slide 26
24 Marines deploy to Liberia 44 contract malaria despite prophylaxis and PPMs UNCLASSIFIED Slide 27
25 What malaria chemoprophylaxis did they take? Issued mefloquine (MQ) Adherence with weekly dosing: 53% Only 10% had serum MQ levels high enough for protection Trop Med Parasitol Sep;44(3): US Marines randomized double-blind clinical trial 250 mg MQ salt weekly (n = 157) 250 mg MQ daily for 3 days followed by 250 mg weekly (n = 46) Steady state MQ plasma levels were attained rapidly with the loading dose regimen in four days versus seven weeks with weekly MQ UNCLASSIFIED Slide 28
26 Take your malaria pills OR ELSE!! MORE THAN HALF THE BATTLE AGAINST DISEASE IS FOUGHT NOT BY DOCTORS, BUT BY REGIMENTAL OFFICERS Slide courtesy of Capt (Ret) Coyne GENERAL WILLIAM SLIM Burma Theatre, WW2 UNCLASSIFIED Slide 29
27 Slide courtesy of Dr. Steven Craig FROM: MACPHERSON, MEDICAL SERVICES HYGIENE, V2, 1924 QUININE PARADE IN GREECE UNCLASSIFIED Slide 30
28 Take home points This will happen again a fever in Sub-Saharan Africa is malaria until ruled out Appreciate geographic variations in transmission intensity Understand malaria chemoprophylaxis Malaria does more than cause fevers Be suspect of adherence to malaria preventive measures The natural history of P. falciparum in non-immunes ends poorly For future GMOs: HNs (E-2s) do not see sick call UNCLASSIFIED Slide 31
29 Social History Activities, hobbies, occupation (defines potential exposures) Examples: hunter, gardener, fishing Sexual practices (e.g. monogamous, MSM, high risk behaviors) Drugs and alcohol (e.g. Needle based drugs, potential for cirrhosis, etc.) Tobacco use (American or foreign made cigarrettes?) Food (OCONUS ( on economy ), imported?) Pets (Type, acquisition history, level of interface) UNCLASSIFIED Slide 32
30 Elderly WM presents with fever, cough, chest pain -Social history reveals chronic tobacco use and alcoholism -ROS reveals poor dentition and occasional aspiration Diagnosis: Lung abscess UNCLASSIFIED Slide 33 Slide courtesy of COL Thomas
31 Family History First degree relatives Immunosuppressive conditions Recurrent infections Individuals sharing household Recent medical events (including vaccinations) Sick contacts Immunosuppressive conditions Recent or current illness If yes, explore diagnosis if known Hospitalized? UNCLASSIFIED Slide 35
32 Travel History (again ) Where (geographic specific infections) When (rainy season = vectors) Activities during travel (urban, rural) Accommodations (hotel with A/C, outdoors) Food (hot, cold, water, hotel, street, etc.) Precautions (any Personal Protective Measures?) UNCLASSIFIED Slide 36
33 Infectious Diseases of Returning Travelers UNCLASSIFIED Slide 37
34 Post-Travel Syndromes/Diseases Febrile/systemic illness Malaria Dengue and other arboviruses Influenza (including Avian forms) Epstein-Barr virus Rickettsial infection Leptospirosis Typhoid Schistosomiasis Viral hemorrhagic fevers Acute or prolonged diarrhea ETEC Campylobacter Salmonella Shigella Entamoeba Vibrio (non-cholera) Giardia Cryptosporidium Cyclospora Isospora Other gastrointestinal Irritable bowl syndrome Strongyloidiasis H. pylori gastritis Ascariasis Hepatitis (A,E) Dermatologic Cutaneous larva migrans Cutaneous leishmaniasis Skin/soft tissue infection Respiratory URI Bronchitis Sinusitis Pneumonia Novel respiratory viruses Genitourinary/STDs Gonorrhea/Chlamydia Syphilis Hepatitis B HIV UNCLASSIFIED Slide 38
35 Med Clin N Am 96 (2012): UNCLASSIFIED Slide 39
36 Stienlauf S et al, Journal of Travel Medicine 12(3): , 2005 UNCLASSIFIED Slide 40
37 UNCLASSIFIED Slide 41
38 UNCLASSIFIED Slide 42
39 UNCLASSIFIED Slide 43
40 Infectious Disease Emergencies UNCLASSIFIED Slide 44
41 Infectious Disease Emergencies Plasmodium falciparum malaria Rickettsial infections Novel Respiratory viruses (including influenza) Acute bacterial meningitis Meningococcemia Cranial subdural empyema Necrotizing soft tissue infections Toxic shock syndrome Viral hemorrhagic fevers Sepsis in patients with splenectomy (actual/functional) Cholera Babesiosis Neutropenic fever Bold = concern for nosocomial transmission UNCLASSIFIED Slide 45
42 Traveler returning from Saudi Arabia after pilgrimage to the Hajj, not feeling well with fever -Develops MS changes, hypotension, and respiratory failure - -Rash as shown below Diagnosis: Meningococcemia UNCLASSIFIED Slide 46
43 Medical History Informing Diagnosis UNCLASSIFIED Slide 47
44 It has been said that a good history listening to the patient allows a diagnosis 90% of the time. Nowhere is a complete and accurate history more important than when approaching a febrile traveler. Schwartz MD. Fever in the returning traveler, part one: a methodological approach to initial evaluation. Wilderness and Environmental Medicine 14; 24-32, UNCLASSIFIED Slide 48
45 Screening Asymptomatic Patients Post- Travel Not a common practice; little evidence to support routine screening for asymptomatic infections Should be considered for some travelers STD screening in sexually active Latent TB screening in healthcare workers or other high risk travelers Other possible considerations Schistosomiasis? Strongyloides? UNCLASSIFIED Slide 49
46 Assumptions about your practice Travel history: you ll know this well since you are deploying with your unit Vaccination history: your unit will generally be UTD Activity based risks: more of an unknown Food intake/ingestions (crayfish, snails, slugs) Animal contact (rabies, tularemia, leptospirosis) Vector exposure and use of PPMs Freshwater exposure Barefoot exposure Sexual exposure Adherence to antimalarial chemoprophylaxis UNCLASSIFIED Slide 50
47 Achitina fulica, the giant African land snail Vaginulus plebeius, the intermediate host of Angiostrongylus costaricensis Slide courtesy of Capt (Ret) Coyne UNCLASSIFIED Slide 51
48 An Outbreak of Eosinophilic Meningitis Caused by Angiostrongylus cantonensis in Travelers Returning from the Caribbean Trevor J. Slom, M.D., Margaret M. Cortese, M.D., Susan I. Gerber, M.D., Roderick C. Jones, M.P.H., Timothy H. Holtz, M.D., M.P.H., Adriana S. Lopez, M.H.S., Carlos H. Zambrano, M.D., Robert L. Sufit, M.D., Yuwaporn Sakolvaree, M.Sc., Wanpen Chaicumpa, Ph.D., Barbara L. Herwaldt, M.D., M.P.H., and Stuart Johnson, M.D., D.T.M.&H. N Engl J Med 2002; 346 (9): , Feb 28 UNCLASSIFIED Slide 52
49 Generalizations about live crawfish eating videos: - Almost exclusively males* - Almost exclusively involve alcohol consumption - Frequently on a dare *muscle shirt optional Slide courtesy of Capt (Ret) Coyne UNCLASSIFIED Slide 53
50 The importance of taking a careful history UNCLASSIFIED Slide 54
51 UNCLASSIFIED Slide 55 Gary Weil, MD
52 Take your malaria pills OR ELSE!! MORE THAN HALF THE BATTLE AGAINST DISEASE IS FOUGHT NOT BY DOCTORS, BUT BY REGIMENTAL OFFICERS Slide courtesy of Capt (Ret) Coyne GENERAL WILLIAM SLIM Burma Theatre, WW2 UNCLASSIFIED Slide 56
53 Slide courtesy of Dr. Steven Craig FROM: MACPHERSON, MEDICAL SERVICES HYGIENE, V2, 1924 QUININE PARADE IN GREECE UNCLASSIFIED Slide 57
54 Mandell et al. PPID 7 th ed. UNCLASSIFIED Slide 58
55 UNCLASSIFIED Slide 59 Mandell et al. PPID 7 th ed.
56 Fever + Rash + Headache + Low platelets (<100k) Rickettsial diseases (i.e. Typhus and Spotted Fevers) - especially if tick exposure and you see an eschar - empiric doxycycline is key Dengue Fever - urban settings can create outbreaks Meningococcal Disease - no vaccine for B - does not always result in meningitis, as it can present as septic shock - need to think about close contacts and post-exposure prophy Early hemorrhagic fevers - present with flu-like symptoms early - they don t all cause bleeding - severe bone pain ( break bone fever ) - can result in hemorrhagic disease - focus on fluid balance in patient - if more joint pain think Chikungunya Sexually Transmitted Diseases - Acute HIV, Syphilis, and even disseminated gonococcal disease - Stress importance of honesty with history UNCLASSIFIED Slide 60
57 Fever + Eschar returning from Sub-Saharan Africa African Tick Bite Fever - Doxycycline will result in rapid symptom resolution African Trypanosomiasis - Known as Sleeping Sickness - East African strain more rapid and severe - Spread by Tsetse fly - Bite leaves a chancre that may look like an eschar - Treatments are complicated and toxic UNCLASSIFIED Slide 61
58 Fever + Hemorrhage Viral Hemorrhagic Fevers - Start with flulike syndrome with rapid progression - Not all cases have hemorrhagic signs - Current Ebola outbreak known for cholera-like diarrhea - Ribavirin has some efficacy against Lassa fever, some hantaviruses and Crimean Congo Hemorrhagic Fever - Early supportive care is key - In majority of cases, risk to the provider is HIGH Meningococcemia - Remember, this bacteria doesn t result in just meningitis - Severe sepsis, and possibility of loss of limbs Leptospirosis - Often associated with water exposure to skin - Not likely if taking doxycycline for malaria prophylaxis Any severe infection can potentially result in hemophagocytic syndrome with cytokine storm UNCLASSIFIED Slide 62
59 Fever + Eosinophilia Schistosomiasis - Exposure to fresh water (look for snail shells) - Acute infection (Katayama fever) occurs within weeks of infection - May have extremely high eosinophil counts - Praziquantel is the drug of choice Trichinosis - Parasite caused by eating undercooked pork or game meats - Early symptoms may be c/w traveler s diarrhea - Later symptoms include muscle pain, edema, and weakness Other intestinal worms that have a tissue migration stage can also result in high eosinophil counts. Malaria does NOT typically result in raised eosinophil levels UNCLASSIFIED Slide 63
60 Other common clinical findings and associated infections Fever + abdominal pain Typhoid, amoebic dysentery/abscess Fever + myalgias/arthralgias Dengue, Chikungunya, O nyong nyong, Ross river virus, Zika virus Fever + jaundice Yellow Fever, Leptospirosis Fever + CNS symtpoms Bacterial meningitis, Angiostrongyliasis, Japanese encephalitis, Tick-Borne encephalitis, African trypanosomiasis, Hendra and Nipah viruses Fever NOS + normal or low WBC Malaria, Visceral Leishmaniasis, Dengue, Rickettsiae, Chikungunya, VHF Fever + tender lymphadenopathy Yersinia pestis (Plague), tularemia Fever with delayed onset (> 6 weeks after return) P. malariae, P. vivax, Tuberculosis, Visceral Leishmaniasis, Schistosomiasis, Meliodosis UNCLASSIFIED Slide 64
61 48 yo man with recent travel to Southeast Asia, presenting with left lower lobe pneumonia, back pain and perirectal abscess Blood cultures and abscess grew a gram negative bacilli identified as a Pseudomonas species Patient was discharged on a 3 week course of levofloxacin Patient returns in 11 days with severe back pain, left sided pleuritic chest pain, and acute bilateral leg paralysis Found to have an epidural abscess tracking from T6-T10 Lab personnel handling the specimens required serologic evaluation for exposure MELIODOSIS UNCLASSIFIED Slide 65
62 Melioidosis (Burkholderia pseudomallei) UNCLASSIFIED Slide 66
63 23 yo male infantryman with 5 days of nonproductive cough starting 2 weeks after returning from Afghanistan, with some low grade fevers, aches and mild pharyngitis. No known exposures. Denies any sick contacts. Did not report spend any significant time living among local nationals or other foreign nation soldiers or support, nor did he participate in any medical treatments among the locals. Would you screen this individual for TB? UNCLASSIFIED Slide 67
64 Global TB Incidence Rates (2009) Source: CDC Health Information for International Travel, UNCLASSIFIED Slide 68
65 Tuberculosis Screening Only screen individuals at high risk of exposure Screening of low risk populations results in high false positive rate Risk factors to consider: Prolonged exposure in high risk regions Significant exposure to local populations Healthcare workers (work, humanitarian) Exposure to high risk settings: prisons/jails, homeless shelters Close contacts of active TB cases 69 UNCLASSIFIED Slide 69
66 48 yo male physician in Kuwait with history of diabetes and 20 pack year smoking history develops fever + severe respiratory disease Works in a hospital in Kuwait City No animal exposure Has had several patients recently with similar symptoms Start with cold-like illness with cough Some GI upset Progression to respiratory failure in some cases with death despite ICU support UNCLASSIFIED Slide 70
67 Middle East Respiratory Syndrome-Coronavirus APRIL FEB 2015 Cases and deaths 1026 lab confirmed cases 376 deaths (37%) Comobidities = HIGH RISK Nosocomial risk Countries in or near Arabian Peninsula Saudi Arabia, United Arab Emirates (UAE), Qatar, Oman, Jordan, Kuwait, Yemen, Lebanon, Iran Travel associated cases United Kingdom (UK), France, Tunisia, Italy, Malaysia, Philippines, Greece, Egypt, United States of America (USA), Netherlands, Algeria, Austria, Turkey UNCLASSIFIED Slide 71
68 22 yo US Marine stationed in Northern Australia with low grade fever, headache, fatigue, body aches, faint rash and symmetric joint pain Several other soldiers in his unit are having similar symptoms since arriving 2-3 weeks ago (early February) Several requesting quarters due to symptoms Rash is maculopapular Marine with some inguinal lymphadenopathy as well Rampant noncompliance with DEET use Concerns raised that this is a new flu UNCLASSIFIED Slide 72
69 Ross River Virus Can cause acute infection with persistence of arthralgias for weeks or months (fatigue may last as well) Not fatal, but can be debilitating Outbreaks occur during wet season especially in tropical coastal areas with salt marshes in the Western South Pacific and is endemic in Australia The vector may vary depending on the region, so biting may occur during the day or the night Diagnose with serology (need acute and convalescent sera) Treatment is supportive (NSAIDs primarily) UNCLASSIFIED Slide 73
70 Initial studies for diagnosis in returned travelers with unexplained fever Thick and thin smears for malaria (supplement with RDTs) Complete blood count with differential and platelet estimate Liver function (standard chemistry) Blood cultures Urinalysis Chest X-rays Additional tests will depend on specific findings and exposures Wilson ME. Fever in returned travelers. CDC Health Information for International Travel, 2010 UNCLASSIFIED Slide 74
71 Take home point number one: ALWAYS include malaria in the differential of fever in a returnee from a tropical locale UNCLASSIFIED Slide 75
72 Keep in Mind that Initial symptoms of life-threatening and self-limited infections can be identical. Malaria is the most common cause of acute undifferentiated fever after travel to sub-saharan Africa and to some other tropical areas. Patients with malaria may be afebrile at the time of evaluation but typically give a history of chills. Malaria, especially falciparum, can progress rapidly. Diagnostic studies should be done promptly and treatment instituted immediately if malaria is diagnosed. A history of taking malaria chemoprophylaxis does not exclude the possibility of malaria. Patients with malaria can have prominent respiratory (including adult respiratory distress syndrome), GI, or central nervous system findings. Wilson ME. Fever in returned travelers. CDC Health Information for International Travel, Page 288 UNCLASSIFIED Slide 76
73 Also Keep in Mind that Viral hemorrhagic fevers are important to identify but are rare in travelers; bacterial infections, such as leptospirosis meningococcemia and rickettsial infections can also cause fever and hemorrhage and should be always be considered because of the need to institute prompt, specific treatment. Sexually transmitted infections, including acute HIV, can cause acute febrile infections. Consider infection control, public health implications and requirements for reportable diseases. Fever in returned travelers is often caused by common, cosmopolitan infections, such as pneumonia, influenza, or pyelonephritis. Common things occur commonly. UNCLASSIFIED Slide 77
74 Take home point number two: Your history taking skills may save a life UNCLASSIFIED Slide 78
75 Take home point number three: Doxycycline?? Consider empiric doxycycline UNCLASSIFIED Slide 79
76 References 1. Schwartz MD. Fever in the returning traveler, part one: a methodological approach to initial evaluation. Wilderness and Environmental Medicine 14; 24-32, Schwartz MD. Fever in the returning traveler, part two: a methodological approach to initial evaluation. Wilderness and Environmental Medicine 14; , Freedman DO, et al. Spectrum of disease and relation to place of exposure among ill returned travelers. New England Journal of Medicine 354: , Wilson ME, et al. Fever in returned travelers: results from the GeoSentinel Surveillance Network. Clinical Infectious Diseases 44 (15 June): , McLellan SLF. Evaluation of fever in the returned traveler. Primary Care and Clinical Office Practice 29: , Magill AJ. Fever in the returned traveler. Infect Dis Clin N Am 12(2): , Speil C, et al. Fever of unknown origin in the returning traveler. Infect Dis Clin N Am 21: , UNCLASSIFIED Slide 80
77 Any questions?? Thailand 2011 UNCLASSIFIED Slide 81
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