Wednesday, October 9, 2013

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


1 comment:

  1. I'm here to give my testimony how I was cured from HIV, I contacted my HIV via blade. A friend of my use blade to peel of her finger nails and drop it where she use it, so after she has left i did know what came unto me i looked at my nails, my nails were very long and I took the blade which she just used on her own nails to cut of my finger nails, as i was maintaining my names, i mistakenly injured myself. I did even bother about it, so when I got to the hospital the next week when i was ill the doctor told me that I am HIV positive, i wondered where did i got it from so i remembered how I use my friend blade to cut off my hand so i feel so sad in my heart to the extent that i don’t even know what to do, so one day i was passing through the internet i met a testimony of a lady that all talk about how she was cured by a doctor called DR Imoloa so i quickly emailed the doctor and he also replied to me and told me the requirements which i will provide and I do according to his command, he prepare a herbal medicine for me which I took. He message me the following week that i should go for a test which i did to my own surprise i found that i was HIV negative. He also have cured for all kinds of incurable diseases like: Huntington's disease, back acne, chronic kidney failure, Addison's disease, Chronic Disease, Crohn's Disease, Cystic Fibrosis, Fibromyalgia, Inflammatory Bowel Disease, Fungal Nail Disease, Paralysis, Celia Disease , Lymphoma, Major Depression, Malignant Melanoma, Mania, Melorheostosis, Meniere's Disease, Mucopolysaccharidosis, Multiple Sclerosis, Muscle Dystrophy, Rheumatoid Arthritis, Alzheimer Disease and so many. Thanks to him once more the great doctor that cured me dr. Imoloa so you can also email him via drimolaherbalmademedicine@gmail.com or what'sapp him on +2347081986098.. God Bless you Sir.

    ReplyDelete