Post Travel Fever. Dr. Eyal Leshem. Center for Geographic Medicine Sheba Medical Center Tel Hashomer, Israel

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Hilary York
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1 Post Travel Fever Dr. Eyal Leshem Center for Geographic Medicine Sheba Medical Center Tel Hashomer, Israel

2 Introduction Fever in returned traveler: Trivial vs. life threatening infections Tropical and travel related vs. cosmopolitan infections Immediate evaluation: Rapidly progressive Epidemiologically important Treatable

3 Introduction Characteristics: Where traveled When traveled How exposed How long (incubation) Immunization history Chemoprophylaxis

4 Epidemiology How common? 2-3% of returned travelers Swiss short term travelers to developing countries: 152/7886 (2%)

6 Fever was reason for seeking care: 6957/24920(28%) Hospitalization: 26% vs. 3% in afebrile pts.

8 Systemic Febrile Illness (35%) Malaria 21% Dengue 6% Enteric Fever 2% Ricketssia 2% Unspecified Febrile Illness (22%) Acute Diarrhea (15%) Travelers Diarrhea Acute gastroenteritis Respiratory Illness (14%) Vaccine Preventable (3%) Pneumonia Bronchitis Tonsilitis Sinusitis Hepatitis A,B Enteric fever

9 Causes of Fever

10 Febrile illness: 124/162 (76%) Malaria - 47 P. falciparum - 22 P. Vivax - 21 P. malaria - 4 P. ovale - 1 Mixed- Dengue - 25 Non-specific unidentified febrile diseases - 24 Febrile diarrheal diseases 10

12 מחלות שכיחות

13 Approach to the Patient Travel and Exposure history: When and where traveled When returned Timing of fever Arthropod exposure (mosquito, tick) Water exposure (rafting bathing in rivers) Accommodation Food and drink habits Sexual exposure Needle or blood exposure

14 Approach to the Patient Vaccination and prophylaxis: Vaccinated? Malaria prophylaxis? Clinical presentation: Additional symptoms or signs Rash Lab and imaging

15 Differential Diagnosis What diagnoses are possible: Symptoms and signs Geography Time of exposure and incubation Exposures Treatable? Transmissible?

17 Travel history

18 Travel history

19 Sub Saharan Africa (N=1401) SE Asia (N=381) Latin America (N=146) North Africa and Middle East (N=103) Falciparum Malaria 30% 2% 0 1% Non Falciparum Malaria 5 % 9 % 4% 4% Ricketssia 5 % 2% 0 1% Dengue 0.1% 13 % 8 % 0% Acute Schistosomiasis 2 % Enteric fever 0.2% 3.4 % 0 0 Cosmopolitan Causes 30% 41% 45% 41% Unknown 24% 21% 33% 39%

22 Dengue 32% FUO 18% Malaria 11% Malaria 64% FUO 11% Diarrhea 11% FUO 14% Leishmania 45% Malaria 9%

23 Incubation Rule out infections not biologically plausible Most severe acute life threatening infections < 3 months post exposure Important infections with late onset 30% vivax malaria pts. In the USA had symptoms > 6 months after return Few causes for fever >2 months post return

24 Causes of Fever According to Incubation Period <2 Weeks 2 Weeks - 2 Months >2 months Malaria Dengue Ricketssia Leptospirosis Enteric Fever Acute HIV Malaria Enteric Fever Acute Schistosomiasis Amebic Liver Abscess Hepatitis A,E Malaria Tuberculosis Hepatitis B Amebic Liver Abscess Visceral Leishmaniasis Melioidosis Rabies

26 Mode of Exposure Arthropod bites Animal contact Water exposure Contaminated food Contact with ill person Sexual contact (5-50%) IVDU, tattoo, dental, blood transfusion

28 Pre Travel Vaccination Chemoprophylaxis Vaccination history Typhoid Malaria chemoprophylaxis what, when and where

29 Clinical Presentations Undifferentiated fever Always look for malaria Falciparum Malaria can be deadly Vivax Malaria can occur despite prophylaxis and months after return Tests repeated every 8-24hrs if initial smear is negative Negative antigen test does not rule out malaria Avoid doctor delay

30 Clinical Presentations Undifferentiated fever Dengue Typical incubation 4-7 days (range 3-14 days) Fever Headache Myalgia Rash (50%) Leukopenia Thrombocytopenia Elevated transaminases

31 Dengue Clinical Presentations Undifferentiated fever 4/104 Israeli travelers (>3 months) 3.4/1000 Israeli travelers in Thailand Dengue hemorrhagic fever Dengue shock syndrome

32 Clinical Presentations Undifferentiated fever Rickettsial infections Treatable Arthropod transmission (ticks, mites) Rash Eschar Fever Headache Lymphadenopathy Leukopenia Thrombocytopenia

33 Eschar

34 Clinical Presentations Undifferentiated fever Enteric Fever Despite vaccination Visit to the Indian subcontinent Fever GI complaints Fatigue Cough Rash (rose spots) Normal blood count Mild elevation transaminase Blood cultures

35 Clinical Presentations Undifferentiated fever Water exposure: Leptospirosis Acute Schistosomiasis

36 Clinical Presentations Fever and CNS Changes Travel related: Falciparum Malaria Meningococcal meningitis African trypanosomiasis (sleeping sickness) Japanese Encephalitis Rabies Cosmopolitan causes: Meningitis Encephalitis

37 Clinical Presentations Fever and Pulmonary findings Travel related Acute Schistosomiasis Legionella (Hotel / Cruise ship) Histoplasmosis Coccidiomycosis Tuberculosis SARS Cosmopolitan causes: Pneumococcal pneumonia Mycoplasma Measles Pertussis Flu

38 Clinical Presentations Fever and Pulmonary findings With Eosinophilia Parasite migration (Loeffler s syndrome): Eosinophilic pneumonia Schistosomiasis Hookworm Ascaris Strongyloides

39 Summary - Mnemonic Symptoms and signs Incubation Travel where Exposed to what Malaria / chemoprophylaxis Immunization

40 Case 1 27 Y/O Dutch tourist 3 months trip in Thailand arrived at Nepal 2 days ago 3 days of: Fever Headache Prostration Myalgia PE: Rash

44 Case 1 Blood count: WBC 1200 HGB 13 PLT Leukopenia Schwartz sign!!!

45 Differential Diagnosis Symptoms and signs Incubation Travel where Exposed to what Malaria / chemoprophylaxis Immunization Treatment? Diagnosis

46 Case 2 42 Y/O Dutch tourist 2 months trip in India and Nepal 4 days of: Fever Cough Prostration PE: mild splenomegaly Lab: Normal CBC, Elevated transaminases

48 Differential Diagnosis Symptoms and signs Incubation Travel where Exposed to what Malaria / chemoprophylaxis Immunization Treatment? Diagnosis

49 Case 3 27 Y/O Israeli Returned from South Africa 7 days ago Safari in Kruger 10 days ago 3 Days fever Headache PE: Lymphadenopathy, rash

51 Case 3 Lab: WBC 5500 HGB 13 PLT

52 Differential Diagnosis Symptoms and signs Incubation Travel where Exposed to what Malaria / chemoprophylaxis Immunization Treatment? Diagnosis

53 Case 4 35 Y/O Israeli Tour guide 5 weeks ago safari in Tanzania 4 days Fever Urticaria Cough

56 Case 4 Lab: WBC 9000 Eo 2300 HGB 14 PLT

57 Differential Diagnosis Symptoms and signs Incubation Travel where Exposed to what Malaria / chemoprophylaxis Immunization Treatment? Diagnosis

59 Case 5 45 Y/O high tech manager Frequent trips to India 5 stars hotels only Last trip 2 months ago 1 Week of fever and abdominal pain PE Diffuse abdominal tenderness no signs of peritonitis Not immunized Did not take malaria prophylaxis

60 Case 5 Lab WBC ALT 300, AST 254 Other tests normal

61 Differential Diagnosis Symptoms and signs Incubation Travel where Exposed to what Malaria / chemoprophylaxis Immunization Treatment? Diagnosis

62 Eli schwartz M.D

63 Eli schwartz M.D

64 Eli schwartz M.D

65 Eli schwartz M.D

Approach to Fever in Patient Return from Travelling. Background. Travelers get sick. 4/17/2013. Adityo Susilo

Approach to Fever in Patient Return from Travelling Adityo Susilo Division of Tropical and Infectious Diseases Department of Internal Medicine FMUI/Cipto Mangunkusumo Hospital Jakarta Background >500,000,000