Fever in the returned traveller
Today in morning report we discussed a patient referred for fever.
The patient was otherwise well with no significant past medical history, not on any medications, no allergies, non-smoker.
The patient had just returned from a trip, travelling with friends
This is a case of fever in the returned traveller.
Things to know:
1.
Where did you go
2.
When were you there (date arrived/left)
3.
What did you do?
a.
Pre-travel: vaccines, pills (malaria proph).
b.
Travel: Itinterary!
i. Purpose:
VFR (Visiting friends and relatives) – increased risk because (perhaps) less
likely to seek pretravel advice, meds, vaccines, they lose innate immunity
ii. Urban
vs rural
iii. Water:
fresh/salt:
- Fresh water fast moving – Lepto
- Fresh water slow moving - schisto
iv. Bites
a.
Mosquitos: malaria (Anopheles- night biters), dengue (Aedes- day biters), yellow fever
b.
Tic: ricketsial, lyme
c. Sandfly (leishmaniasisi)
d.
Others include: mites, fleas (plague)
v. Exposures:
a.
Human: sexual
b.
Dogs/bats: rabies
c. Other animals: goats, rodents
d.
Food: bottled water? Local
- Diarrheal
bugs (salmonella typhi), hep A, unprocessed cheese (brucella)
4.
Illness itself
-
Associated Symptoms
o
Retro-orbital pain: think dengue (+/- rash few
days later)
o
Conjunctivitis: think leishmaniasis
o
Hematuria: think schisto
o
Resolving fever followed by terrible arthritis:
Chikungunya (means “leaning forward”, because bent over with pain)
o
Rose spots, relative brady, diarrhea (sometimes
constipation in adults) think typhoid
Our case:
Onset of fever 1 day before returning home. Generally unwell. Headache. 3 days later rash developed.
7 days abroad. Water sports ie scuba. No fresh water
exposure. No animal exposures. No sexual activity. Pre-travel received vaccinations for hepatitis A, yellow fever.
Diagnostic approach to FTR (Fever in the Returned Traveller):
related infection
vs unrelated infection vs not infection (ie VTE, drug fever)
Think about long incubation that may have been acquired
prior to leaving OR short incubation that was acquired during trip
Influenza: short incubation period 12-48 hours
Hep A, B, C, HIV, longer incubation periods
Infections related to travel
**FTR is always malaria until proven otherwise: ie that you
determine that malaria is not endemic in that area or 3x thick/thin smears
negative.
(malaria, typhoid, dengue, hep A account for ~80% of
diseases from tropics)
Given the constellation of symptoms, the diagnosis here was
Dengue.
Dengue
-
most common mosquito borne illness
-
SA/Caribbean, SE asia
-
Aedes mosquito (day biters)
-
Urban
-
4 types 1,2,3,4
-
Once get one type of dengue will be immune. BUT
if you get dengue with a second type, higher (though still small) chance of bad
complications
-
Retroorbital pain, bone pain are classic features,
rash
-
Dengue hemorrhagic fever: low plt, plasma
leakage
-
Measles mimics
-
Incubation time is ~7 days (often 3-4d)…after 14
days can feel like out of the woods.
-
Supportive management
For more on FTR see this NEJM review article
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