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An unwanted souvenir

An unwanted souvenir . Fever in the returning traveller Francesca Savioli . http://www.sweetmarias.com/coffee.africa.tanzania.php. You’re the GP at a west end practice…. Jamie 22 years old Returns from 6 week elective in Tanzania Pyrexia >38.5°C for 3 days (up&down)

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An unwanted souvenir

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  1. An unwanted souvenir Fever in the returning traveller Francesca Savioli http://www.sweetmarias.com/coffee.africa.tanzania.php

  2. You’re the GP at a west end practice… • Jamie • 22 years old • Returns from 6 week elective in Tanzania • Pyrexia >38.5°C for 3 days (up&down) • 1 episode diarrhoea this morning • Feels rotten: tired, ache-y, shivery • Headache

  3. What do you want to know? • Any illness while away? • Where did he go? • Any unprotected sex? • Any strange bites (animals/insects) • Anyone else ill in the group? • Contact with any animals? • Vaccination status?

  4. History • Back 1 week ago • Symptoms started 2 days ago • Cold –> hot -> sweaty • Being “kinda” careful but tried a few dishes from dodgy stalls + staff canteen • Tried to drink bottled water when possible • Slept under a net but wasn’t getting much sleep as he had a lot of late shifts at the hospital so would be out at sunset • Sometimes forgot to take his antimalarials • Didn’t really bother with the non-essential vaccines (unsure which ones he got)

  5. On examination • Temperature 39.5°C • HR 120 • Conjunctival pallor • A bit yellow? • Liver palpable 1cm • Spleen palpable 2cm

  6. Differential diagnosis? • Malaria • Typhoid • Dengue/ other viral fevers • Viral Hepatitis • “Traveller’s diarrhoea” • Influenza • Amoebic liver abscess

  7. What do you do next? • Investigations: • FBC – anemia, thrombocytopenia • U&E – creatinine • LFT – slightly deranged Specifics: • Blood films – thick and thin giemsa - ?malaria • Rapid malaria test • Blood culture -?salmonella • Serology -?dengue • Abdo USS (liver) • Stool sample • Urine sample

  8. http://www.msf.org.uk/malaria_day_2008_opinion_piece_230408_20080423.newshttp://www.msf.org.uk/malaria_day_2008_opinion_piece_230408_20080423.news

  9. http://www.springerimages.com/Images/RSS/1-10.1007_s00431-011-1451-4-1http://www.springerimages.com/Images/RSS/1-10.1007_s00431-011-1451-4-1

  10. Malaria WHO archive pictures accessed via: http://wikieducator.org/File:Plasmodia.jpg#filehistory http://ipmworld.umn.edu/chapters/curtiscf.htm

  11. Plasmodium • Protozoan parasite • P. falciparum • cerebral • pregnancy • P. vivax • P. ovale • P. malariae Anopheles mosquito

  12. http://www.medicinenet.com/malaria/article.htm

  13. http://www.plans2travel.co.uk/malaria-needs-to-be-taken-seriously-by-holidaymakers/http://www.plans2travel.co.uk/malaria-needs-to-be-taken-seriously-by-holidaymakers/

  14. Potential complications – (i.e. what kills you) • P.falciparum • Anemia (haemolysis) • Cerebral malaria – seizures (sequestration) • Metabolic acidosis (Kussmaul breathing) • Hypoglycaemia • Acute tubular necrosis (renal failure) • Pulmonary oedema (ARDS) • Complications in pregnancy • P. vivax • Hypnozoites in the liver: reactivation

  15. Management • P.falciparum: • Riamet (artesunate+amodiaquine) • Coartem (artemether+lumefantrine) • If severe: IV artesunate derivatives or Quinine • Other “benign” malarias: • Chloroquine • Or Primaquine • Supportive (fluids, antipyrexials, bed rest)

  16. Prevention • Bednets +/- insecticide-treated • Insecticide • Long sleeves during mosquito biting times especially (sunset/2-3am/sunrise) • Antimalarials • Lariam (mefloquine) • Malarone (atovaquone+proguanil) • Doxycycline

  17. http://erin.faintlight.com/

  18. Enteric fevers • Salmonella typhi + paratyphi • Faeco-oral • Headache • Malaise • Fever • Constipation (+/- diarrhoea after week 1) • Occasionally: rose spots (trunk), splenomegaly, abdominal pain

  19. Enteric fevers cont. • Blood culture • +/- urine/stool cultures later • Rx: Ciprofloxacin first line • cefotaxime IV if severe http://ilovebacteria.com/salmonella.htm

  20. Thank you! Questions/Past Papers? Photograph: F. Savioli

  21. Useful Reading • Oxford Handbook of Clinical Medicine • British National Formulary – Antibiotics for each condition • Paediatrics microbiology booklet/handout • Medicine at a Glance – Davey (Wiley- Blackwell Publishers) • CDC website

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