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Fever of traveler return from tropical area (1)

HKCEM College Tutorial. Fever of traveler return from tropical area (1). Author Dr. Poon Kin Ming Oct, 2013. A case. 50/M, smoker, GPH C/O fever for 5 days Also has sore throat, cough, myalgia, poor appetite, chills, headache SOB, chest pain –ve

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Fever of traveler return from tropical area (1)

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  1. HKCEM College Tutorial Fever of traveler return from tropical area (1) Author Dr. Poon Kin Ming Oct, 2013

  2. A case • 50/M, smoker, GPH • C/O fever for 5 days • Also has sore throat, cough, myalgia, poor appetite, chills, headache • SOB, chest pain –ve • Seen GP once and just partial improvement • Recalled travel history to Thailand 10 days ago for a trip • Vitals stable

  3. What would you like to ask more in the history ?

  4. History • TOCC What does it stand for ? - Others symptoms ? • Chemoprophylaxis or vaccination before the trip • Mosquito bite / insect bite /animal contact • Onset of fever : Incubation period • Fever pattern

  5. On further history • Travel : Thailand for 4 days, noted fever 2 days after back to HK • Occupation : teacher • Contact / cluster –ve • No chemoprophylaxis or vaccination before the trip • Mosquito bite +

  6. Physical exam: • Alert, responsive • Temp 38.1C, Jaundice & pallor –ve • BP118/55mmHg, Pulse 88/min • RR 16/min , SpO2 98% on RA • Chest clear & no heart murmur • Pharynx congested + • A 1cm lymph node over L side of the neck • Maculopapular skin rash over the body, petechiae –ve • Neck stiffness –ve • Liver & spleen not palpable • Multiple joints pain but calf soft

  7. Measles-like skin rash • The rash consists of macular lesions that are red and usually 2–10 mm in diameter but may be confluent in places • Morbilliform refers to a rash that looks like measles http://upload.wikimedia.org/wikipedia/commons/9/91/Denguerash.JPG

  8. Patient with fever after return from tropical region • What is your differential diagnosis in general ?

  9. Diagnosis • Infectious diseases esp. tropical illness • Autoimmune diseases • Malignancy

  10. Infectious diseases that should not be missed

  11. What is tropical region?

  12. Continent visited

  13. Incubation periods

  14. Fever pattern

  15. Physical signs

  16. Clinical diagnosis • Dengue fever, • Infectious mononucleosis, • Influenza, • Rickettial infection, • Malaria, • Typhoid fever • Other non-infectious causes e.g. malignancy, auto-immune

  17. Patient’s progress – fever pattern

  18. Investigation • WCC : 3.9 (N : 4.5 -11x 10 9 /L) Differential count : neutropenia & lymphopenia • HGB :14.9 (N : 14 – 17.5 x 10 9/ L ) • Platelet : 100 (N: 150 – 450 x 10 9/ L) • INR normal • APTT prolonged to 42.1 sec • R/LFT normal • Malaria parasite –ve

  19. Progress – lab. result

  20. Dengue fever 登革熱 • A viral disease transmitted by the infected mosquito, Aedes aegypti (埃及伊蚊) • In HK, most abundant species is Aedes albopictus (白紋伊蚊) • 4 dengue virus serotypes • Most common serotype in HK is type 1 • A statutory notifiable diseases in HK • About 3-17 cases per year

  21. Aedes Aegypti 埃及伊蚊 www.giron.co.cu/es/noticia/social/lucha-contra-el-aedes-aegypti-alertas-en-todo-momento

  22. Dengue fever • Incubation period of dengue infection is 4 to 7 days • Fever usually lasts for 5 to 7 days • Another name : break bone fever • Clinical presentation ranges from non- specific febrile illness to severe life threatening conditions such as dengue hemorrhagic fever (DHF) & dengue shock syndrome (DSS)

  23. Dengue Hemorrhagic fever http://www.niaid.nih.gov/SiteCollectionImages/topics/denguefever/michaelRossmannStory.JPG

  24. Dengue fever 登革熱 • Dengue hemorrhagic fever (DHF) : Dengue fever + Hemorrhagic tendency + Plasma leakage (>20%) • Dengue shock syndrome : (DSS) DHF + shock + rapid pulse with narrow pulse pressure < 20mmHg

  25. Pathophysiology of DHF & DSS • Rarely occurs in primary infection as host develops life long immunity only against specific serotype • In secondary infection with another serotype, the a/b at primary infection cross reacts & forms complexes with viral antigen, which enhances the phagocytosis by mononuclear cells. • The virus replicates inside the cells, which release the vasoactive immune mediators causing DHF & DSS

  26. http://mednews.com/wp-content/uploads/dengue-virus-296x300.jpghttp://mednews.com/wp-content/uploads/dengue-virus-296x300.jpg

  27. Treatment • Mainly supportive • Steroid & antiviral agents not effective • Paracetamol as antipyretic agent • Avoid aspirin as worry of Rye’s syndrome • No vaccine available • Vector (mosquito) control

  28. Summary • Tropical infection, especially the Dengue fever, Malaria, Rickettsial diseases& Typhoid & Paratyphoid • Protection against the vector (mosquito) • Chemoprophylaxis against malaria before the trip

  29. Summary • Exclusion of life threatening infection or diseases with public health risk (e.g. measles, rubella) is the priority • Life threatening infections include Falciparum malaria, dengue haemorrhagic fever/ dengue shock syndrome, leptospirosis, infective endocarditis and meningoccocaemia.

  30. Any questions ?

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