Transcript View - Department of Medicine

Traveler with a
fever
Case presentation
Ann Schmidt
CASE
 68 yo woman presented to the ER with
several day history of fever and one day
history of confusion.
Past Medical History
 NIDDM for several years, well controlled
 Coronary heart disease with bypass
grafting x 3 one year ago
 Mild Hypertension
Social History
 Has lived in Madison for >10 years but
husband and some family members are
still in Nigeria, her home town.
 Lives alone
 No pets
 Nonsmoker
 Rare Alcohol.
Family History
 Positive for heart disease and diabetes.
 No breast or colon cancer
 Family members in the US are healthy.
Review of Systems
 Family reports she was well on arrival
home.
 No initial fever, chills, sore throat, resp.
illness or GI symptoms.
 Her first complaint was arthralgias,
followed by fevers to 102 – 105.
 Mild confusion started on the day of
admission, worsened by the afternoon.
ER evaluation
 Labs – Normal CBC, glucose,
electrolytes and BUN/Creatinine.
 Head CT – normal
 Chest X-ray – normal
 Urinalysis – trace ketones, + 2 Protein
Evaluation of fever in the
international traveler
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

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Did they get pre-travel advice?
Did they follow the advice?
Where did they travel and how?
When did they get sick – before they
returned home or several weeks later?
Incubation periods
 <10 days – Dengue, Traveler’s diarrhea,
Yellow fever, Spotted fevers.
 10-21 days – typhoid fever Leptospirosis,
Malaria, Typhus Viral hemorrhagic fevers.
 >21 days – Acute HIV infection, Amebic
liver abscess, Malaria, Tuberculosis and
all viral hepatitis.
Most Common
 Malaria is the most common cause of
fever in the traveler returning from the
tropics. 27%-42%
 Dengue 8%
 Hepatitis 6%
 Enteric fever 3%
Visiting Friends and
Relatives ( VFR’s)
 Huge problem and the rate of infection is
increasing
 Reason – They do not take the
prophylaxis.
 500 million infections, 1 million deaths
 They feel like they are immune from the
diseases they grew up with.
Who gets Travelers
malaria?
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
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
VFR’s 23%
Tourist 12%
Business 9%
Missionary 11%
Peace Corps 2%
Malaria Deaths
 1992-2001 4685 malaria cases in US
citizens
 19% took inappropriate. Drug
 56% took nothing
 In the US about 6 deaths a year
Clinical presentation
 Fever and influenza symptoms
 These symptoms occur at intervals.
 Some have anemia and jaundice ( think
hepatitis)
 Some have diarrhea ( think travelers
diarrhea)
 As early as 6 days, or months later.
Malaria
 Four types – falciparum, vivax, ovale,
and malariae.
 Anopheles mosquito
 P. falciparum –the worst – seizures,
mental confusion, kidney failure and
coma.
 Transmission at dawn and dust.
Chemoprophylaxis
 When and where are they at risk for
exposure?
 What type of malaria is there?
 More resistance to falciparum is being
reported – Thailand, Burma, and Cambodia
Drugs
 For Chloroquine sensitive areas
 Chloroquine 500 mg tab, once a week
starting one week prior and continuing four
weeks after.
 May exacerbate psoriases
Chloroquine resistant
 Mefloquine (Lariam)
 Falling out of favor
 Contraindications – Psych anything,
Epilepsy – decreases seizure threshold,
Cardiac conduction defects
 250 mg each week
More Drugs
 Doxycycline – Low cost but DAILY
dosing.
 Adverse effects – GI upset, vaginal
candidasis, photosensitivity
The New Kid on the block
 Malarone – atovaquone 250mg, +
proguanil 100 mg.
 FDA approved July 2000
 Contraindicated with renal impairment
 Take DAILY
 EXPENSIVE
How to prevent failure
 My patient had seeked advice – often
with VFR’s this does not happen
 Cost and drug interaction was a problem
 Patient still travels to Nigeria and only
treats herself if she becomes ill.
 She has now been hospitalized twice for
Malaria.
Conclusion
 Talk to patients about travel during the
physicals or other visits as appropriate.
 Review vaccinations – compare Hep A
and Hep B to the combined shot.
 Modes of travel can be the most
dangerous part of the trip.
Dr. Stanford’s Bottom line
 If I had 90 seconds and the traveler
possessed only limited funds, I would
address :
Malaria,
Hepatitis A,
Seatbelts,
And condoms.
Bibliography
 Lo Re, VL and Gluckman SJ. “Travel Immunizations.”
Am Fam Physician 2004;70(1):89-99, 103-4.
 Blair JE. “Evaluation of Fever in the International
Traveler.” Postgrad Med, 2004;116(1):13-29.
 “The Malaria Controversy.” Prescribers Letter Detail
Document 181006.
 Centers for Disease Control and Prevention. Health
Information for the International Traveler 2001-2002.
Atlanta: US Department of Health and Human
Services, Public Health Service, 2001.
Internet Sites
 www.malaria.org
 www.tripprep.com
 www.cdc.gov
 www.istm.org