OBJECTIVES SCOPE OF THE ISSUE GEOSENTINAL DATA

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Darlene Norton
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OBJECTIVES Discuss the approach to fever in the

available when approaching a patient that will be

interesting case presentations of fever in

world Understand the importance of pre travel

1 OBJECTIVES Discuss the approach to fever in the returning traveler Understand the resources available when approaching a patient that will be or who has traveled internationally Review a few interesting case presentations of fever in individuals returning from various parts of the world Understand the importance of pre travel counseling SCOPE OF THE ISSUE GEOSENTINAL DATA Ann Intern Med. 2013;158:

ILLNESS IN LONG TERM TRAVELERS VISITING GEOSENTINEL CLINICS GEOSENTINAL DATA 15

2013;158:456 468 EPIDEMIOLOGY EPIDEMIOLOGY The reporting rate ratios (in cases per

infections, according to the region of travel Nature Reviews Microbiology 7, 895

2 ILLNESS IN LONG TERM TRAVELERS VISITING GEOSENTINEL CLINICS GEOSENTINAL DATA 15 37% experience a health problem Ann Intern Med. 2013;158: EPIDEMIOLOGY EPIDEMIOLOGY The reporting rate ratios (in cases per million travelers) of acquiring viral, bacterial and parasitic gastrointestinal infections, according to the region of travel Nature Reviews Microbiology 7, (December 2009) doi: /nrmicro2238 Nature Reviews Microbiology 7, (December 2009) doi: /nrmicro2238

THE CONTINUUM OF TRAVEL MEDICINE Pre Travel Contingency Preventive Medicine During Travel Planning Treatment & Rehabilitation Visitors Post Travel OBTAINING A HISTORY OF THE RETURNING TRAVELER WITH

) Vaccinations and malaria prophylaxis Other drugs taken while or since traveling Immune status (diabetes, glucocorticoid treatment, renal failure, splenectomy, diseases associated with immune

3 THE CONTINUUM OF TRAVEL MEDICINE Pre Travel Contingency Preventive Medicine During Travel Planning Treatment & Rehabilitation Visitors Post Travel OBTAINING A HISTORY OF THE RETURNING TRAVELER WITH FEVER HISTORY Day by day itinerary Visits with relatives or friends while abroad (Was anyone ill?) Vaccinations and malaria prophylaxis Other drugs taken while or since traveling Immune status (diabetes, glucocorticoid treatment, renal failure, splenectomy, diseases associated with immune deficit) Consumption of unclean water, unpasteurized milk, or improperly cooked or raw food Exposure to fresh water (rafting, kayaking, swimming in rivers or lakes, floods) Skin contact with soil (e.g., walkingbarefoot) Tattoos, piercings, intravenous drug use, or medical procedures (e.g., injections and blood product transfusions) Sexual contact, specifically unprotected sex with a new partner, commercial sex workers, or multiple partners Insect or animal bites Close contact with animals or wild or pet birds Thwaites GE, Day NPJ. N Engl J Med 2017;376: INCUBATION PERIODS OF COMMON TROPICAL ILLNESSES PREVALENCE OF TROPICAL DISEASES ACCORDING TO PERIOD BETWEEN RETURN OR ARRIVAL FROM ENDEMIC COUNTRIES AND FEVER ONSET* Short(<7-10 days) Intermediate (w/in 1 month) Long (>3 months) Dengue fever Amebic liver abscess Amebic liver abscess Malaria CMV, EBV Bartonellosis Diphtheria Hep A, C, E HIV, Hep B,C HIV HIV Rabies Influenza Acute schistosomiasis Syphilis Rickettsial diseases Trypanosomiasis TB Leptospirosis Brucellosis Arboviruses Malaria Typhoid fever Bottieau, E. et al. Arch Intern Med 2006;166:

Did she take any medicine? Any other symptoms, PMHx?

4 When did she go? Where did she go? What was her days like? Day by day itinerary Did she visit a travel medicine clinic? Did she take any medicine? Any other symptoms, PMHx? 46 yo woman with fever and headache of 3 day duration after coming from India

Laboratory Tests & Images Complete blood count Complete metabolic panel Thick and thin blood

availableurinalysis and urine culture Blood, stool and other body fluid/tissues cultures

Serology testing (e.g., dengue, brucellosis, leishmaniasis, amebiasis or other parasites, etc.

5 Laboratory Tests & Images Complete blood count Complete metabolic panel Thick and thin blood films to screen for malaria (3 times over 24 hours) Dip stick malaria assay, if availableurinalysis and urine culture Blood, stool and other body fluid/tissues cultures Smear for fecal leukocytes Microscopic examination of stool for ova and parasites HIV test Serology testing (e.g., dengue, brucellosis, leishmaniasis, amebiasis or other parasites, etc.), PCR testing. Imaging studies: Chest x ray or other plain films, ultrasound, CT and MRI CASE Malaria Map2018

MALARIA SEVERE MALARIA CLINICAL FEATURES Impaired consciousness/coma Prostration or sit up with assistance Convulsions Deep breathing, respiratory distress

Pulmonary edema (radiologic) PATHOPHYSIOLOGY Parasitemia > 5% Sequestration of erythrocytes with mature forms of the parasite in deep vascular beds of vital

More likely to cause complicated malaria P vivax P ovale P malariae More likely to cause uncomplicated malaria, can cause more severe illness More likely to

6 MALARIA SEVERE MALARIA CLINICAL FEATURES Impaired consciousness/coma Prostration or sit up with assistance Convulsions Deep breathing, respiratory distress (acidotic breathing) Circulatory collapse/shock, systolic blood pressure <70 mm Hg Jaundice Hemoglobinuria Abnormal spontaneous bleeding Acute renal failure Pulmonary edema (radiologic) PATHOPHYSIOLOGY Parasitemia > 5% Sequestration of erythrocytes with mature forms of the parasite in deep vascular beds of vital organs small infarcts, capillary leakage, and organ dysfunction Anemia, thrombocytopenia 10 20% fatality with treatment TYPES OF MALARIA Plasmodium P falciparum More likely to cause complicated malaria P vivax P ovale P malariae More likely to cause uncomplicated malaria, can cause more severe illness More likely to cause uncomplicated malaria Less likely to cause relapse than P vivax More likely to cause uncomplicated malaria Very low level of parasitemia Can have long latency period up to years

7 RAPID DIAGNOSTIC TESTS DIAGNOSIS P. falciparum sensitivity and specificity for this test are 95% and 94%, respectively P. vivax sensitivity and specificity are 69% and 100% DIAGNOSIS AND TREATMENT: CDC GUIDELINES Part 1 CDC Malaria Hotline: (770) (855) (770) after hours. DIAGNOSIS AND TREATMENT: CDC GUIDELINES Part 2 CDC Malaria Hotline: (770) (855) (770) after hours JAMA. 2007;297(20): doi: /jama

8 When did he go? What was his days like? Day by day itinerary Did he visit a travel medicine clinic? Did he take any medicine? Any other symptoms, PMHx? 43 yo man returning from a 10d trip to Flores, Indonesia with fever and rash

TYPICAL PRIMARY DENGUE INFECTION WITH TIMING OF DIAGNOSTIC TESTS

Geneva; World Health Organization: 2009: Geneva; World Health Organization:

9 TYPICAL PRIMARY DENGUE INFECTION WITH TIMING OF DIAGNOSTIC TESTS WorldHealthOrganizationand the Special Programme for Research and Training in Tropical Diseases. Dengue: guidelines for diagnosis, treatment, prevention and Control. Geneva; World Health Organization: 2009: WorldHealthOrganizationand the Special Programme for Research and Training in Tropical Diseases. Dengue: guidelines for diagnosis, treatment, prevention and Control. Geneva; World Health Organization: 2009:

A 21 year old female presents to your ED with fever and chills for 10

pain. She is more constipated than usual. She has no past medical history.

In Peru, she stayed in homes and mostly urban areas, but also went hiking.

missed 1 2 doses. Her vital signs are: Temp 38.

10 A 21 year old female presents to your ED with fever and chills for 10 days She complains of fatigue, headache, malaise and crampy abdominal pain. She is more constipated than usual. She has no past medical history. She has recently traveled to Peru. All immunizations are up to date. In Peru, she stayed in homes and mostly urban areas, but also went hiking. She took malaria prophylaxis before and after the trip, but may have missed 1 2 doses. Her vital signs are: Temp 38.2 C, BP 115/60, HR 43 bpm, Oxygen saturation 98%. On exam, appears well. Her GCS is 15 and her neck is supple. Her abdomen is slightly distended, with mild diffuse tenderness, but no peritoneal signs. Her CBC is normal, she has mildly elevated liver enzymes.

Classsic Symptoms Relative bradycardia is often described.

Look for rose spots on the trunk and extremities salmon colored, blanching,

constipation, dry cough, frontal headache, delirium, and an increasingly stuporous

relative bradycardia Week 3: weight loss, conjunctival injection, tachypnea, thready

psychosis, peritonitis SUMMARY SLIDES FEVER IN THE RETURNING TRAVELER CLINICAL SYNDROMES

11 Classsic Symptoms Relative bradycardia is often described % constipation can be seen in patients. Look for rose spots on the trunk and extremities salmon colored, blanching, maculopapules usually 1 4 cm wide and fewer than 5 in number which generally resolve within 2 5 days. Presentation Divided into 3 weeks: Week 1: diffuse abdominal pain and tenderness, constipation, dry cough, frontal headache, delirium, and an increasingly stuporous malaise Week 2: Rose spots, progression of GI symptoms with abdominal distension, relative bradycardia Week 3: weight loss, conjunctival injection, tachypnea, thready plulse, crackles over the lung bases, pea soup diarrhea, apathy, confusion, and even psychosis, peritonitis SUMMARY SLIDES FEVER IN THE RETURNING TRAVELER CLINICAL SYNDROMES Fever, rash, arthalgia (FAR) Arboviral infections: dengue, zika, mayaro, chikungunya <10 days Fever, rash, sore throat, lymphadenopathy HIV seroconversion illness EBV Streptococcal pharyngitis Fever + jaundice Hepatitis Yellow Fever Malaria Hepatic abscess Amebic Bacterial

RASHES IN SYSTEMIC INFECTIONS Fever, headache, malaise within 1 2 weeks of infection Maculopapular, vesicular, or petechial rash or an eschar at the site of tick bite.

encephalitis Activity Raw, undercooked food Contaminated seafood Salt water exposure Untreated water/milk Fresh water exposure Sexual contact Animal exposure Tattooing, piercing EXPOSURE HISTORY

12 RASHES IN SYSTEMIC INFECTIONS Fever, headache, malaise within 1 2 weeks of infection Maculopapular, vesicular, or petechial rash or an eschar at the site of tick bite.think: African tick bite fever Southern Africa, tache noir Mediterranean spotted fever Northern Africa, rash, fever Scrub typhus Asia, can have lymphadenopathy, cough, hearing difficulties, and encephalitis Activity Raw, undercooked food Contaminated seafood Salt water exposure Untreated water/milk Fresh water exposure Sexual contact Animal exposure Tattooing, piercing EXPOSURE HISTORY Disease Risk Hepatitis, enteritis V. vulnificus, M.marinum, Aeromonas Salmonellosis, shigellosis Schistosomiasis, leptospirosis Syphilis, GC, HIV Rabies, Q-fever, plague, tularemia, borreliosis HIV, hepatitis B,C Insect bites Mosquitos Ticks Reduviid bugs Tsetse flies EXPOSURE HISTORY Disease risk Malaria, Dengue Typhus, borreliosis, relapsing fever Chagas disease (American trypanosomiasis) African trypanosomiasis (sleeping sickness) SERIOUS TRANSMISSIBLE INFECTIONS IN FEBRILE RETURNING TRAVELERS Thwaites GE, Day NPJ. N Engl J Med 2017;376:

SERIOUS TRANSMISSIBLE INFECTIONS IN FEBRILE RETURNING TRAVELERS GUIDELINES FOR THE EVALUATION OF NON FOCAL FEVER IN THE RETURNED TRAVELER ALWAYS consider mundane causes such as urinary

DO NOT forget to consider non travel related causes: Fever may have nothing to do with the trip If the incubation period appears to be short (less than 21 days) Majority of patients will

N Engl J Med 2017;376:548-560 GUIDELINES FOR THE EVALUATION OF NON FOCAL FEVER IN THE RETURNED TRAVELER If the incubation period appears to be long (more than 21 days) Majority of

13 SERIOUS TRANSMISSIBLE INFECTIONS IN FEBRILE RETURNING TRAVELERS GUIDELINES FOR THE EVALUATION OF NON FOCAL FEVER IN THE RETURNED TRAVELER ALWAYS consider mundane causes such as urinary tract and upper respiratory tract infections. DO NOT forget to consider non travel related causes: Fever may have nothing to do with the trip If the incubation period appears to be short (less than 21 days) Majority of patients will have malaria, typhoid fever, or dengue fever. Rickettsial diseases (also a short incubation period) are becoming more frequent causes of fever in returned travelers. Thwaites GE, Day NPJ. N Engl J Med 2017;376: GUIDELINES FOR THE EVALUATION OF NON FOCAL FEVER IN THE RETURNED TRAVELER If the incubation period appears to be long (more than 21 days) Majority of patients will have malaria or tuberculosis. Consider hepatitis A in unimmunized patients. Consult with an ID subspecialist early if the patient is particularly ill or has altered mental status. Although meningococcemia and viral hemorrhagic fevers are highly uncommon, consider these diagnoses, because they are medical emergencies.

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

Post Travel Fever. Dr. Eyal Leshem. Center for Geographic Medicine Sheba Medical Center Tel Hashomer, Israel Post Travel Fever Dr. Eyal Leshem Center for Geographic Medicine Sheba Medical Center Tel Hashomer, Israel Introduction Fever in returned traveler: Trivial vs. life threatening infections Tropical and