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Emergency Department Evaluation of Fever in the Returning Traveler

Emergency Department Evaluation of Fever in the Returning Traveler. Dr. Aric Storck October 31, 2002. Objectives. Approach to the febrile traveler History Travel history Vaccinations Chemoprophylaxis Laboratory studies Treatment overview of common imported diseases. Background.

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Emergency Department Evaluation of Fever in the Returning Traveler

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  1. Emergency Department Evaluation of Fever in the Returning Traveler Dr. Aric Storck October 31, 2002

  2. Objectives • Approach to the febrile traveler • History • Travel history • Vaccinations • Chemoprophylaxis • Laboratory studies • Treatment • overview of common imported diseases

  3. Background • >500,000,000 people cross international boundaries each year • >12,000,000 North Americans travel to developing countries each year •  international travel =  importation of exotic infectious diseases Suh, K, et al. Evaluation of Fever in the Returned Traveler. Medical Clinics of North America 1999:83(4)997-1018.

  4. Travelers get sick …. • 20-70% of travelers report health problems while traveling • 1-5% seek medical attention abroad • 0.01-0.1% require emergency medical evacuation • 1 in 100,000 dies Kain K, Ryan E. Health Advice and Immunization for Travelers. NEJM 2000;342(23)1716-1725.

  5. 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

  6. For example … • Study of 353 North American passengers boarding international flights to regions where Hepatitis A is endemic • 72% did not obtain immunizations • 78% did not know the route of transmission of hepatitis A • 95% unable to identify fever, abdominal pain, jaundice as symptoms • 88% of flight crew were not immunized • Quoted in: Thanassi M, Thanassi W. EMR 1998;9(22)239-246

  7. The result …. • 1-2% of unimmunized travelers visiting a developing country for >1 month will develop hepatitis A • Steffen R. Risk of hepatitis A in travelers: the European experience. Journal of Infectious Disease 1995;171:S24-28. • 300 / 100,000 travelers / month in tourist areas of developing countries • 5-7 x increased risk for “backpackers” • Quoted in:Kain K, Ryan E. Health Advice and Immunization for Travelers. NEJM 2000;342(23)1716-1725.

  8. After the holiday … • Swiss study • 4% of travelers to developing countries for >3 weeks develop fever • 61-71% remained febrile upon return Steffen R, et al. Health problems after travel to developing countries. J Infect Dis 1987;156:84-91. • 5% of travelers consult MD upon return Thanassi M, Thanassi W. EMR 1998;9(22)239-246

  9. Many of the returning ill will present to the Emergency Department!

  10. ED evaluation of the febrile traveler • What infections are possible given the patient’s travel history • What infections are probable given the patient’s medical history and presentation • What infections are life-threatening or contagious or both

  11. General Medical History • Immunocompromise • Increased risk of all infectious diseases • Decreased gastric acidity (achlorhydria, H2 blockers, PPI) • Increased risk of enteric illness (eg: cholera, typhoid) • Chronic respiratory disease • Increased risk of respiratory infections

  12. Asplenia • Encapsulated organisms • Sickle Cell Trait / G6PD deficiency • Confer protection against malaria

  13. Pre-travel History • ? pre-departure medical consultation • Vaccination status • Which vaccines • When • Chemoprophylaxis • Which specific medication • Dosing schedule • Patient compliance

  14. Travel Immunizations

  15. Vaccination against the following makes diagnosis unlikely: • Yellow fever • Hepatitis A • Hepatitis B • Vaccinations for following are not very effective • Typhoid • Cholera

  16. Travel History • Precise dates of travel • Arrival & departure from endemic regions • Countries and regions visited • Urban • Rural • Type of accommodation •  hotel • Bamboo hut

  17. Infection prophylaxis • Insect repellants • Mosquito nets • Bottled water • Activities • Freshwater exposure (rafting, swimming...) • Trekking • Contact with animals • Drug use

  18. Sexual contacts • 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;32:1063-1067.

  19. 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;32:1063-1067.

  20. Commonest causes of fever (%) sources: O’Brien D, et al.Clinical Infectious Diseases 2001;33:603-9. Suh, K, et al. Medical Clinics of North America 1999:83(4)997-1018.

  21. Incubation Periods • Short (<1 week) • GI bacterial pathogens • Dengue Fever • Yellow Fever • Medium (1-2 weeks) • Malaria • Typhoid • Trypanosomiasis

  22. Incubation Periods • Long (>3 weeks) • Viral hepatitis • Malaria • Schistosomiasis • Tuberculosis • Amoebic liver abscess • Rabies

  23. FeverAssociated Signs and Symptoms

  24. Frequency of presenting symptoms in febrile returned travelers O’Brien D, et al. Fever in Returned Travelers. Clinical Infectious Diseases 2001;33:603-9

  25. 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 • Malaria

  26. Jaundice • Hepatitis A • Most common cause • Yellow fever • Hemorrhagic fevers • Leptosporosis • Malaria • 20% jaundiced secondary to hemolysis

  27. Respiratory complaints • The usual suspects • CAP, influenza • Tuberculosis • Usually due to reactivation • Suspect in immigrants, not in travelers • P.falciparum • ARDS (often fatal) • Helminths • Strongyloides, schistosoma, ascaris • Protozoa • Entamoeba histolytica, trypanosoma

  28. Dermatologic complaints • Rose spots - Typhoid • faint pink macules/papules on trunk • Maculopapular exanthem • Dengue fever • Viral hemorrhagic fevers • Petechiae / ecchymotic lesions • Meningococcemia • Dengue • Viral hemorrhagic fevers

  29. Neurologic complaints • Meningitis • Meningococcal • Aseptic (enterovirus, rickettsiae, typhoid...) • Encephalitis • Arbovirus (eg: Japanese encephalitis) • Cerebral malaria (P.falciparum) • Looks like toxic coma • Consider empiric antimalarial therapy if neurologic SSx and diagnosis uncertain

  30. Splenomegaly • Common and non-specific • Malaria • OR 7.9; 95% CI 2.4-27.3; P<0.001 O’Brien D, et al. Fever in Returned Travelers. Clinical Infectious Diseases 2001;33:603-9 • Trypanosomiasis • Dengue

  31. Hepatomegaly • Malaria • OR 4.0; 95%CI 1.3-12.5; P=0.006 O’Brien D, et al. Fever in Returned Travelers. Clinical Infectious Diseases 2001;33:603-9

  32. Lymphadenopathy • EBV • HIV • Dengue • NOT in malaria

  33. Typhoid Fever Salmonella typhi

  34. Typhoid Fever • Gram negative bacilli • Salmonella typhi • Salmonella paratyphi • Fecal-oral route • Contaminated food or water • Incubation period 5-21 days

  35. Typhoid Fever • Endemic in almost all developing countries • 16,000,000 clinically significant cases annually (WHO) • Many more subclinical cases • 600,000 deaths annually

  36. Typhoid Fever

  37. Typhoid Fever

  38. Classical Presentation • Week 1 • Fever • Bacteremia • Week 2 • Abdominal pain • Rash (Rose spots) • Week 3 • Hepatosplenomegaly • Intestinal perforation / hemorrhage

  39. diagnosis • Laboratory • Anemia • Leukocytosis / leukopenia • Abnormal LFTs • Isolation of bacteria • Blood culture – positive in 40-80% • Stool culture – positive in 30-40% • Bone marrow – positive in 98%

  40. Treatment • Fluoroquinolone • Ciprofloxacin 500 mg bid • Ofloxacin 400 mg bid • Plus 3rd generation cephalosporin • High levels of resistance in some strains • Continue while sensitivities pending • Ceftriaxone 2-3 g od

  41. Typhoid Mary … • 2-5% of hosts become asymptomatic carriers • Very high risk of transmitting disease to others if involved in food preparation • Mary Mallon – responsible for 54 cases of typhoid and 3 deaths in New York

  42. Hepatitis A • Most common vaccine-preventable illness in travelers • Fecal-oral transmission via food and water • Risk as high as 2 cases / 100 travellers / 4 week stay • 10-100x more common than typhoid • 1000x more common than cholera • Thanassi M, Thanassi W. EMR 1998;9(22)239-246

  43. Hepatitis A • Incubation period 15 – 30 days • Fever in pre-icteric phase • Often asymptomatic in children • Jaundice by age group • <6 = <10% • 6-14 = 40-50% • >14 = 70-80%

  44. Hepatitis AComplications • Fulminant hepatitis • Cholestatic hepatitis • Relapsing hepatitis • No chronic sequelae • Overall mortality 1:1000 cases (varies widely according to age)

  45. Hepatitis A

  46. Hepatitis A From:http://www.worldwidevaccines.com/public/diseas/hepa23.asp

  47. Age Specific Mortality Source: CDC

  48. Diagnosis & Treatment • Clinical • Fever • Jaundice • RUQ pain • Laboratory • Transaminitis • Cholestatis • Hepatitis serology • Treatment • Supportive

  49. Dengue Fever

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