CLINICAL APPROACH TO TROPICAL DISEASES

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1 CLINICAL APPROACH TO TROPICAL DISEASES Somphong Narkpinit, M.D. Department of Pathobiology Faculty of Science, Mahidol University somphong.nar@mahidol.ac.th SCBM346 Tropical infectious diseases and controls

2 Prevalent in tropical and subtropical regions Atypical presentations confusing to the clinician Non-infectious disease e.g. autoimmune or malignant conditions should be excluded

3 Tropical and Subtropical Regions

4 History of Present Illness : Ask about MUSCATS Mode of fever : duration and fluctuation severity Used medication and investigation,vaccine,previous medication Symptom : rash jaundice lymph nodes pain cough Contact with animals and sick people Admission Travel history : include location, time since return, locale (eg. in back country, only in cities), vaccinations received before travel and any use of prophylactic antimalarial drugs. All patients should be asked about possible exposure (eg. via unsafe food or water, insect bites, animal contact or unprotected sex) Sex - Unprotected

5 Common Tropical Infectious Diseases in Thailand Leptospirosis Rickettsioses: Scrub typhus Murine typhus Melioidosis Enteric fever Typhoid fever Paratyphoid fever Nontyphoidal salmonellosis Tuberculosis Malaria Dengue infection Helminthic infection Infective diarrhea

6 Important modes and diseases transmitted

7 Common Fever Syndromes 1. Fever 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Hepatorenal involvement

8 Fever Malaria Typhoid fever HIV Dengue Leptospirosis Rickettsia Relapsing fever Other viral illness

9 Fever - Huge list of potential causes - Vast majority caused by standard infection; UTI, LRTI etc. - Malaria should always be considered - Falcifarum rare > 3 months after leaving endemic area - Vivax / ovale may persist for year

10 Incubation period < 21 days - Malaria - Enteric fever - Arbovirus, e.g. dengue, chikungunya - Gastroenteritis - Typhus (louse borne, flea born, scrub) - American Thypansomiasis - Leptospirosis - Viral haemorrhagic fevers

11 Incubation period > 21 days - Malaria - TB - Viral hepatitis - HIV - Schistosomiasis (Katayama fever) - Amoebic liver abscess - Leishmaniasis - Filariasis

12 Usual incubation periods of some febrile infectious illnesses

13 Fever and localizing signs Rash dengue, typhoid, HIV, syphilis, typhus Jaundice malaria, hepatitis, leptospirosis Lymphadenopathy HIV, TB, typhus Hepatomegaly malaria, hepatitis, leptospirosis, amoebic liver abscess, typhoid Splenomegaly malaria, typhoid Eschar typhus, CCHF, tick-borne encephalitis

14 Differential diagnosis of physical findings for some infectious febrile diseases

15 Laboratory investigations 1) Date of onset of fever a. NS1 Ag in Dengue: 2-5 days b. Blood culture: 1st week in Salmonella c. IgM for : Scrub, Dengue, Leptospira, Typhi dot: 2nd week 2) Rapid diagnostic tests / bedside tests a. Malaria Rapid diagnostic test (high negative predicative value b. Dengue NS1 Antigen 9High positive predictive value)

16 Investigations CBC, UA, LFT s Malaria EDTA sample repeat if suspicious Blood cultures Save serum for serology Urine analysis and culture (+/-OCP) Stool for MC&S and OCP Host stool Amoebiasis Fresh stool Strongyloides CXR Check G6PD status before prescribing Primaquine

17 Common Fever Syndromes 1. Fever 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Hepatorenal involvement

18 Neurologic Syndromes :Encephalitis Fever, headache, altered mental status, convulsions, coma Cerebral malaria Meningitis JE Encephalitis scrub typhus; typhoid encephalopathy Herpes simplex virus Trypanosomiasis (sleeping sickness) HIV

19 HIV Chronic Meningitis : TB, cryptococcal Toxoplasmosis HIV dementia

20 Malaria

21 What are malaria symptoms and signs? Malaria Complications - Cerebral Malaria - Blackwater fever - Pulmonary edema - Very low blood of sugar - Hemolysis - Coagulopathy

22 Plasmodium falciparum : ring hemorrhage

23 Symptom of malaria Headache Pallor Severe hemolytic anemia Heart failure Cerebral malaria impaired mental status, convulsion, coma Labored breathing acidosis, heart failure

24 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Hepatorenal involvement

25 Abdominal Syndromes Fever, abdominal pain Typhoid Infectious colitis : shigella, E.coli, Salmonella, Campylobacter, ameba Amebic liver abscess Appendicitis, pyelonephitis HIV

26 Fever and Diarrhea Shigella and Entamoeba histolytica Salmonella, Campylobacter and Cryptosporidium are common worldwide Enteric fevers (Typhoid and paratyphoid) Typhoid vaccine, 50-70% efficacy Management : Stool sample +/- empirical antibiotics e.g. ciprofloxacin Persistent diarrhea is usually caused by protozoan parasites such as Cryptosporidium and Giardia

27 Typhoid Salmonella Typhi Rose spots

28 Typhoid Fever Typhoid fever is a life-threatening illness caused by the bacterium Salmonella Typhi. Typhoid fever is also known as enteric fever, bilious fever It is a gram-negative short bacillus that is motile due its flagellum Gram-negative bacteria are pathogenic, meaning they can cause disease in a host organism

29 Typhoid Sustained high fever, headach Apathy, psychosis Constipation, abdominal pain Splenomegaly

30 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Hepatorenal involvement

31 Pulmonary Syndromes Fever, cough, dyspnea Pneumonia Tuberculosis HIV Scrub typhus; leptospirosis complicated malaria

32 Tuberculosis 1/3 rd world TB infected 5%-10% will develop tuberculosis disease Risk greatest within the first five years Only Pulmonary TB is infectious esp. smear positive Extra-pulmonary TB (LN, GI) more common in migrants than UK born, 48% vs 27% Problems of multi-resistant TB organisms Test :PPD (Mantoux skin test) BCG vaccine

33 Tuberculosis - Clinicals Suspect if chronic fever, cough, weight loss and unexplained symptoms Investigations : 3 x Early morning sputum CXR Other CBC, LFT Referral to Infectious Diseases or Chest clinic

34 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Hepatorenal involvement

35 Rash Fever and skin rash Koplik spot Measles HIV Dengue Other viruses Leptospirosis Rickettsial infections, including scrub typhus Purpura fulminance in Meningococcal meningitis

36 Tropical skin disease Fungal infections common in hot climates and with HIV Acute schistosomiasis Cutaneous lava migrans Larva currens strongyloides Cutaneous leishmaniasis Myiasis Tungiasis Eschars HIV associated skin lesion

37 Skin lesions associated with febrile infections

Differential diagnosis of fever with rash Lesion Pathogens or Infection a) Maculopapular rash : central distribution VRS Measles, rubella, roseola, erythema infectiosum, EBV, echovirus, HBV,

38 Differential diagnosis of fever with rash Lesion Pathogens or Infection a) Maculopapular rash : central distribution VRS Measles, rubella, roseola, erythema infectiosum, EBV, echovirus, HBV, HIV BACT Erythema marginatum (rheumatic fever, scarlet fever), erysipelas, 2 o syphilis, leptospirosis, Lyme dzs RICK Rocky Mountain Spotted fever, Scrub typhus OTH RA, Kawasaki dis, drug rxn

39 Erythematous patch with central clearing Erythema marginatum

Differential diagnosis of fever with rash Lesion a) Maculopapular rash : peripheral distribution Erythema multiforme Pathogens or Infection VRS HSV,

40 Differential diagnosis of fever with rash Lesion a) Maculopapular rash : peripheral distribution Erythema multiforme Pathogens or Infection VRS HSV, EBV, echovirus BACT 2 o syphilis, leptospirosis, Lyme dzs, RICK Rocky Mountain Spotted fever OTH Radiation Rx, drug rxn, Meningococcemia and dengue fever

41 b) Diffuse erythema with desquamation Scarlet fever Toxic shock syndrome and scalded skin syndrome Strawberry tongue

Lesion Pathogens or Infection d) vesicular, pustular, bullous VRS HSV, EBV, Coxsackievirus BACT Staph.

Crusted impetigo RICK Rickettsial pox OTH Toxic epidermal necrolysis, Steven-Johnson Syndrome e)

Dengue virus BACT Sepsis (meningococcal, gonococcal, pneumococcal, Hib), IE, weil syndrome (severe

42 Lesion Pathogens or Infection d) vesicular, pustular, bullous VRS HSV, EBV, Coxsackievirus BACT Staph.SSS, Staph. Bullous impetigo, Strep. Crusted impetigo RICK Rickettsial pox OTH Toxic epidermal necrolysis, Steven-Johnson Syndrome e) Petechial - purpuric VRS Atypical measles, congenital rubella, CMV, enterovirus, HIV, HF viruses, Dengue virus BACT Sepsis (meningococcal, gonococcal, pneumococcal, Hib), IE, weil syndrome (severe lepto) OTH Vasculitis, thrombocytopenia, Henocj-Schonlein purpura, malaria Generalised bone narrow failure (e.g. leukaemia, aplastic anaemia, myeloma, marrow infiltration by solid tumours)

43 f) Erythema Nodosum VRS EBV, HBV BACT Group A streptococcus, TB, yersinia, Cat-Scratch Dzs Fungi-Sarcoidosis, Inf. Bowel dzs, OCP, SLE, Behcet dzs

44 MEASLE Characteristic Explanation Causative agent Measles virus (ssrna paramyxovirus) Host Invade Transmitted by Virus present Period of communicability Human Upper respiratory tract, regional LN Large respiratory droplets with no fomites (close contact transm.) Respiratory secretion, blood, urine Contagious from 5 days before to 4 days after the appearance of rush.

45 CONJUNCTIVITIS KOPLIK SPOTS MACULAR RASH

46 Dengue

47 Dengue Asia, South America Marked myalgia, eye pain

48 Rickettsia Fever, headache, and myalgia Clue : tick exposure, painless eschar African tick-bite fever, scrub typhus Weil-Felix test for Rickettsial disease ( nonspecific antibodies to Proteus strains)

49 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Hepatorenal involvement

50 Hemorrhagic Syndromes Hematemesis, melena, epistaxis, petechiae, purpura, puncture site bleeding Ebola, Lessa, Marburg Yellow fever Dengue Severe leptospirosis (Weil syndrome) purpuric rash

51 Common Fever Syndromes 1. Fever alone 2. Neurologic 3. Abdominal 4. Pulmonary 5. Rash 6. Hemorrhage 7. Hepatorenal involvement

52 Fever with hepatorenal involvement a. Rule out malaria; leptospirosis; scrub typhus, Enteric fever b. Jaundice after fever : hepatitis A-E with FHF

53 Viral Hepatitis Hepatitis A or E rare, mainly from Indian subcontinent Chronic carriage of Hep B up to 20% Hep C carriage UK 0.5%, Africa 5%, Asia 2.5% Value of routine screening Abnormal LFT can reflect a vast number of different diseases Detection allows vaccination of susceptible family member (Hep B)

54 Leptospirosis

55 Leptospirosis Cause Incubation Period 7-14 Days Host Clinical Features Leptospira interrogans Exposure to water contaminated with animal urine First Phase (3-10) Days Second Phase Severe Leptospirosis (Weil s Syndrome) High grad fever Severe Headache Myalgia Abdominal pain Conjunctival suffusion Maculopapular rash Meningitis Iridacyclitis Intense jaundice Renal failure Hypotension Hemorrhage-Pulmonary, GI, ICH, Pericardium, Conjunctival Purpuric Rash

56 Leptospirosis Rash Aseptic meningitis Conjuntivitis /suffusion Hepatomegaly Jaundice Lung involvement

57 Approach to the patients with tropical infections

59 Management strategy for tropical fever syndrome

60 References 1. Singhi S, Chaudhary D, Varghese GM, Bhalla A, Karthi N, Kalantri S, Peter JV, Mishra R, Bhagchandani R, Munjal M, Chugh TD, Rungta N. Tropical fevers: Management guidelines. Indian J Crit Care Med Feb;18(2): Abrahamsen SK, Haugen CN, Rupali P, Mathai D, Langeland N, Eide GE, et al. Fever in the tropics: Aetiology and case-fatality-aprospective observational study in a tertiary care hospital in South India. BMC Infect Dis 2013;13: Chrispal A, Boorugu H, Gopinath KG, Chandy S, Prakash JA, Thomas EM, et al. Acute undifferentiated febrile illness in adult hospitalized patients: The disease spectrum and diagnostic predictors-an experience from a tertiary care hospital in South India. Trop Doct 2010;40: John TJ, Dandona L, Sharma VP, Kakkar M. Continuing challenge of infectious diseases in India. Lancet 2011;377: Frean J, Blumberg L. Tropical fevers part A. Viral, bacterial and fungal infections. Primer of Tropical Medicine. Ch. 5A. Brisbane:ACTM Publication; p Available from: HYPERLINK tropmed.org/primer/chapter%2005a.pdf tropmed.org/ primer/chapter 05a.pdf. [Last accessed on 2013 Dec 23] 6. Hai Err, Viroj Wiwanitkit. Syndromic approach to diagnosis and treatment of critical tropical infections. Indian J Crit Care Med. Jul 2014; 18(7): 479.

What infections do returned travellers bring back to Australia?

+ What infections do returned travellers bring back to Australia? Sarah McGuinness (sarah.mcguinness@monash.edu) MBBS, DTMH, MPH&TM, FRACP Infectious Diseases Physician, Alfred Hospital PhD candidate,