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

Transcription

1 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 people cross international boundaries each year international travel = importation of exotic infectious diseases WHO 2010 : 940 million people travels around the world WHO 2020 the number is going to be 1,6 Billion!! Suh, K, et al. Evaluation of Fever in the Returned Traveler. Medical Clinics of North America 1999:83(4) WHO Travel Health 2012 Travelers get sick % of travelers report health problems while traveling 1-5% seek medical attention abroad % require emergency medical evacuation 1 in 100,000 dies Kain K, Ryan E. Health Advice and Immunization for Travelers. NEJM 2000;342(23)

2 Low awareness of traveler s health issues Many travelers do not seek predeparture medical consultation Poor understanding of risks Not covered by health insurance Shortage of physicians with travel medicine expertise WHO. IHR Fever Physiological process as a respond to disease, by increment of body temperature above the normal level as a result of exogenous pyrogen stimulation to the hypothalamus Normal body temperature range 36,2 0 C 37,7 0 C Diurnal variation Fever > 36,2 0 C in the morning and > 37,7 0 C in the evening Cause of Fever Substance causing fever = PYROGEN Exogenous Pyrogen Endogenous Pyrogen Microbial Agent Virus, bacteri, fungi, parasite Microbial Toxin Microbial degradation products Endotoxin Eksotoxin Enterotoxin, TSS, toxin-1, exotoksin pirogenik streptokokus, toksin eritrogenik Peptidoglikan, peptida muramil, asam lipoteikoik, polimer glukosa ramnosa, lipoarabinomannan 2

3 Pathogenesis & Pathophysiology of Fever Hypothalamic endothelium Fever in Traveller : Important to Evaluate INFECTION? Travel History Incubation Periods of Infectious Diseases Signs and symptoms other than fever Endemicity of disease in various geographical area 3

4 Pre-travel History? pre-departure medical consultation Vaccination status Which vaccines? When? Chemoprophylaxis (eg. Malaria) Which specific medication? Dosing schedule? Patient compliance? Travel History Precise dates of travel Arrival & departure from endemic regions (incubation period) Countries and regions visited Urban Rural (risk exposure to vectors, sanitation) Type of accommodation hotel Bamboo hut (risk exposure) Infection prophylaxis Insect repellants Mosquito nets Bottled water Activities Freshwater exposure (rafting, swimming...) Trekking Contact with animals Drug use 4

5 Sexual contacts : HIV and STDs? 66% of 213 Australians going to Thailand reported plans to have sex 25% of Swedish women on charter holidays reported a sexual encounter with an unknown partner 18.6% of 757 patients at Hospital for Tropical Diseases in London reported new sexual partner during last trip Only 36% regularly used condoms Quoted in: Matteelli A, Carosi G. Sexually Transmitted Diseases in Travelers. Clinical Infectious Diseases 2001;32: Sex and the long-term traveler 60% of 1080 Peace Corps had sexual encounter with new partner 40% with local partner 1/3 used condoms 50% of Belgian expatriates in Central Africa reported extramarital sex 1/3 with commercial sex workers Quoted in: Matteelli A, Carosi G. Sexually Transmitted Diseases in Travelers. Clinical Infectious Diseases 2001;32: Most common causes of fever in traveller (%) diagnosis MacLean et al (n=587) Doherty et al (n=195) O Brien et al (n=232) Malaria Hepatitis (Hep A) Respiratory infection Urinary tract infection Dysentery (gastroenteritis) Dengue fever Enteric fever Tuberculosis Rickettsial infection Acute HIV infection Amebiasis Other infections Non-infectious causes Undiagnosed sources: O Brien D, et al. Clinical Infectious Diseases 2001;33: Suh, K, et al. Medical Clinics of North America 1999:83(4)

6 Incubation Periods Short (<1 week) GI bacterial pathogens Dengue Fever Yellow Fever Medium (1-2 weeks) Malaria Typhoid Trypanosomiasis Incubation Periods Long (>3 weeks) Viral hepatitis Malaria Schistosomiasis Tuberculosis Amoebic liver abscess Rabies Important additional symptoms 6

7 Diarrhea Traveler s Diarrhea (e. coli) Most common travel related illness Only 15% febrile Dysentery (bloody diarrhea) Campylobacter, Salmonella, Shigella Typhoid 30-50% c/o diarrhea Viral, protozoal, helminth Jaundice Hepatitis A Most common cause Yellow fever Hemorrhagic fevers Leptosporosis Malaria 20% jaundiced secondary to hemolysis Respiratory complaints The usual suspects CAP, influenza Tuberculosis Usually due to reactivation Suspect in immigrants, not in travelers P.falciparum ARDS (often fatal) 7

8 Dermatologic complaints Rose spots - Typhoid faint pink macules/papules on trunk Maculopapular exanthem Dengue fever Viral hemorrhagic fevers Petechiae / ecchymotic lesions Dengue Viral hemorrhagic fevers Neurologic complaints Meningitis Meningococcal Aseptic (enterovirus, typhoid toxic) Encephalitis Arbovirus (eg: Japanese encephalitis) Cerebral malaria (P.falciparum) Looks like toxic coma Consider empiric antimalarial therapy if neurologic SSx and diagnosis uncertain Organomegaly Common and non-specific Malaria OR 7.9; 95% CI ; P<0.001 O Brien D, et al. Fever in Returned Travelers. Clinical Infectious Diseases 2001;33:603-9 Dengue Leptospira Abscess (E.hystolotica) 8

9 Short Resume Fever in designated area visits CDC. Yellow book

10 Incubation and Distribution CDC. Yellow book 2012 Incubation and Distribution.. (2) CDC. Yellow book 2012 Important clinical considerations in Tropical Areas CDC. Yellow book

11 Thank You 11