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 travel related vs. cosmopolitan infections Immediate evaluation: Rapidly progressive Epidemiologically important Treatable

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

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

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

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

Causes of Fever

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

מחלות שכיחות 50 45 47 40 35 30 25 20 15 10 5 24 25 11 17 10 5 4 5 4 3 2 2 3 0

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

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

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

Travel history

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 % 0 0 0 Enteric fever 0.2% 3.4 % 0 0 Cosmopolitan Causes 30% 41% 45% 41% Unknown 24% 21% 33% 39%

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

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

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

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

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

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

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

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

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

Eschar

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

Clinical Presentations Undifferentiated fever Water exposure: Leptospirosis Acute Schistosomiasis

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

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

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

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

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

Case 1 Blood count: WBC 1200 HGB 13 PLT 70000 Leukopenia Schwartz sign!!!