Transcript Infections to Consider in Febrile Children Returning from Overseas

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THE FEBRILE TRAVELER: INFECTIONS TO CONSIDER IN FEBRILE
CHILDREN RETURNING FROM OVERSEAS
Oloruntosin Adeyanju, MD, FAAP 1
Sangeeta Krishna, MD, FAAP1
Andrea Rivera-Sepulveda, MD, MSC, FAAP2
Navjyot Vidwan, MD, MPH, FAAP3
Laura Voegele, MD, FAAP3
1. Cleveland Clinic Children’s; 2. Washington University School of Medicine, Cardinal Glennon Children's Hospital ; 3. University of Louisville School of Medicine
DISCLOSURE STATEMENTS
We have no relevant financial relationships with the
manufacturers(s) of any commercial products(s) and/or provider of
commercial services discussed in this CME activity.
We do not intend to discuss an unapproved/investigative use of a
commercial product/device in this presentation.
A QUICK SURVEY
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NO LONGER LIFESTYLES OF THE RICH & FAMOUS
Travel is increasingly popular
• In 2013, > 1 billion international tourist arrivals, up >57% from 2003
• Over the past 10 years, consistently >60 million US residents travel
abroad annually, with similar numbers of inbound international
travelers
As are travel-related diseases
• 1,500 malaria cases/year in the U.S.
• In 2014, >9,000 new TB cases, almost 3,000 Chikungunya cases
Low rates of pre-travel health visits, especially in travelers visiting friends &
relatives
ISN’T IT JUST A VIRUS?
Differential diagnosis changes significantly with some travel
exposures
• Asia & sub-Saharan Africa are most common sources of travelrelated illness
• Most frequent traveler complaints are Gastrointestinal >
Febrile> Dermatologic
Appropriate management of some “exotic diseases” requires
appropriate clinical suspicion and timely detection
• Often requires different testing, empiric treatments, and patient
surveillance than “local” illnesses
OBJECTIVES
At the end of this workshop, participants will be able to
⋆ Describe a general approach to the child presenting with a fever
and an international travel history
⋆ Recognize key features of some infections commonly acquired
overseas
⋆ Identify useful resources to guide testing and treatment of these
infections
INTRODUCTION
Caused by Mycobacterium Tb, slow growing acid fast bacilli
One third of the world’s population is estimated to be infected
(WHO, 2008)
Prevalent in certain geographic areas
Risk factors: travel, foreign born, immune- suppressed, HIV,
international adoptees, refugees
Photo Credit: Dr. George P. Kubica, CDC Public Health Image Library (PHIL #5789) phil.cdc.gov
Image Credits: Centers for Disease Control and Prevention www.cdc.gov/tb/publications/factsheets/statistics/tbtrends.htm
World Health Organization Global Tuberculosis Report 2015. apps.who.int/iris/bitstream/10665/191102/1/9789241565059_eng.pdf
A 17y/o is admitted with 3 weeks of low grade fever, weight loss,
anorexia, fatigue, night sweats and cough. He spent the summer in
Guatemala and returned 4 months ago.
Photo Credit
1. Satyakamk, via Wikimedia Commons https://commons.wikimedia.org/wiki/File%3AThinkingMan_Rodin.jpg
2. CDC Public Health Image Library (PHIL #14805) phil.cdc.gov
HOW DOES IT SPREAD?
Person to person spread via droplet/ airborne
Prolonged close contact
Most infections involve the lungs/larynx
• TB disease (pulmonary vs extra-pulmonary)
• Latent TB (pulmonary)
Photo Credit: http://www.cdc.gov/tb/webcourses/TB101/page1699.html
EXTRAPULMONARY TB
Isolated LN
CNS
Abdomen (peritonitis,
obstruction, Addison’s,
salpingitis)
Bone/joints
Eyes (iritis, phlycten)
Skin (erythema nodosum)
Photo credits:
1. Dr.J.S.Bhandari, India via Wikimedia Commons commons.wikimedia.org/wiki/File%3ATubercular_adinitis_with_sinus.JPG
2. Digital Reference of Ophthalmology dro.hs.columbia.edu/phlyctenular.htm
CASE
3 year old Jung presented with fever, and mental status changes and
has been admitted with TB meningitis. He immigrated to the US with
his parents one year ago. His CXR is normal, he does not have
pulmonary disease and sputum specimen collected by gastric
aspirates did not show any AFB on stain or culture. His disease is
reported to the health department and he is started on the
appropriate drug regimen.
TB MENINGITIS
How would Jung have gotten Tb meningitis?
Droplet, airborne-> hematogenous
Should a contact investigation be done?
Not needed, he is not contagious
Should a source investigation be done?
Yes, always
How should Jung be isolated in the hospital?
Standard precautions (no pulmonary disease)
AT BIRTH, JUNG RECEIVED THE BCG
IN CHINA…
Rates of protection against tuberculosis infection vary widely.
Protection lasts 10-20 years.
BCG prevents about 20% from getting infected and among
those infected, it protects half from developing disease
BCG does not prevent reactivation of latent pulmonary
infection
DIAGNOSIS IS CLINICAL
PPD/ TST- indicates exposure, does not differentiate latent from
active disease
May take up to 12 weeks to become positive
May be negative with malnutrition, anergy (miliary Tb), young age
and viral infections.
Interpretation is based on age/risk profile
Needs to be read within 48-72hrs
Photo from Wikimedia Commons upload.wikimedia.org/wikipedia/commons/9/9d/Mantoux_test.jpg
PPD IS POSITIVE IF..
Induration 5mm
 HIV-infected persons
 A recent contact of a person with
TB disease
 Fibrotic changes on CXR consistent
with prior TB
 Organ transplant recipient
 Immunosuppressed for other
reasons (e.g. taking the equivalent
of >15 mg/day of prednisone for 1
month or longer, taking TNF-a
antagonists)
Induration 10mm
 Recent immigrant (< 5 years) from
high-prevalence countries
 Injection drug users
 Resident/employee of high-risk
congregate settings
 Mycobacteriology laboratory
personnel
 Clinical conditions that place them at
high risk
 Children < 4 years of age
 Infants, children, and adolescents
exposed to adults in high-risk
categories
Induration 15mm
 Any person, including
persons with no known risk
factors for TB
 However, targeted skin
testing should only be
conducted among high- risk
groups
DIAGNOSTIC TESTS
Cultures- CSF, pleural/pericardial/joint fluid, bone marrow or tissue
Imaging
IGRA (Interferon gamma release assay)- more specific if prior BCG,
but still does not differentiate latent from active disease
NAAT/PCR- can identify bacterium and resistance patterns
STANDARD THERAPY
TABLE 3. TREATMENT REGIMENS FOR DRUG-SUSCEPTIBLE TUBERCULOSIS IN INFANTS, CHILDREN, AND ADOLESCENTS
INFECTION OR DISEASE CATEGORY
Regimen
Remarks
LATENT M TUBERCULOSIS INFECTION
(POSITIVE TST OR IGRA, NO DISEASE, CHEST
X-RAY NORMAL OR WITH HEALED DISEASE)
INH SUSCEPTIBLE
9 mo. of INH, once a day
If daily therapy is not possible, DOT twice a week
can be used for 9 mo.
PULMONARY AND EXTRAPULMONARY
(EXCEPT MENINGITIS)
2 mo. of RIP, INH, PZA, and EMB (RIPE)
daily or twice weekly, then 4 mo. of INH
and RIF by DOT.
A 3-drug initial regimen (INH, RIF, and PZA) may be
considered if the risk of drug resistance is low.
If hilar adenopathy only and the risk of drug
resistance low, a 6-mo course of INH and RIF is
sufficient. Drugs can be given 2 or 3 times/wk.
under DOT.
Adapted from: American Academy of Pediatrics. Tuberculosis. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book®: 2015 REPORT OF THE COMMITTEE
ON INFECTIOUS DISEASES. American Academy of Pediatrics; 2015; 805-831
TREATMENT
Standard therapy
Airborne precautions
Tailor to resistance
patterns if known
Negative pressure
N95 mask
MDR-T (primary or
acquired) and XDR-T
Direct Observed Therapy
http://www.cdc.gov/tb/webcourses/TB101/page107.html
CASE PRESENTATION
6 year old female
Fever, frontal headache, abdominal pain and constipation
Dx with viral syndrome
Two days later, returns to the ED
•
•
•
•
persistent fever
continued headache
worsening abdominal pain
one day of rash on the trunk and abdomen
Image source: medicineonlinepk.blogspot.com/2013/09/enteric-fever.html
DIFFERENTIAL DIAGNOSIS
Viral syndrome
• Fifth’s Disease, EBV, Adenovirus, Enterovirus
Influenza
Viral GE
Viral meningitis
Image By Centers for Disease Control and Prevention, via CNN cnn.com/2014/09/12/health/going-abroad-10-diseases
TYPHOID FEVER
Potentially severe and occasionally life threatening febrile
illness
• Salmonella enterica serotype Typhi
• Salmonella enterica serotype Paratyphi A, B or C
22 millions cases; 200,000 related deaths
• US – 300 culture confirmed cases of typhoid, 100 cases of
paratyphoid
• >80% acquired from travel to Southern Asia
• Other high risk areas: East and Southeast Asia, Africa, Caribbean,
and Central and South America
CLINICAL PRESENTATION
Classic Presentation:
First Week – Fever; GI symptoms including abdominal pain; dry cough, dull frontal headache. End
of the first week fever plateaus around 103-104. Patient may develop rose spots on the trunk.
Second Week – Symptoms worsen. Abdomen becomes distended. Splenomegaly.
Third Week – The patient grows more toxic and anorexic. Abdominal distension worsens. Some
patients develop small quantity, foul smelling green colored diarrhea. The patient may progress
into the “typhoid state” characterized by apathy, confusion, psychosis; possible bowel
perforation and intestinal hemorrhage
Fourth Week – Fever, mental state and abdominal distension slowly improve. Weakness and
weight loss continue for months. Some survivors become asymptomatic carriers.
DIAGNOSIS / WORK UP
Primarily clinical
Infection with typhoid or paratyphoid fever results in low-grade
septicemia
•
•
•
•
•
Cultures: Blood, bone marrow, stool & urine
Rectal Swab
Punch Biopsy
Widal Test
PCR
OTHER NONSPECIFIC TESTS
Most patients are
•
•
•
•
•
•
•
Anemic
Elevated ESR
Thrombocytopenia
Relative lymphopenia
Elevated PT and PTT, decreased fibrinogen levels
LFTs and serum bilirubin rise to twice normal
Mild hyponatremia and hypokalemia
TREATMENT
Broad Spectrum Antibiotics
• Patients with unexplained symptoms returning from an endemic
area of typhoid within 1-60 days should be empirically treated
• Start immediately prior to culture positive results
• Reduces the risk of complications and mortality
Compliant patients with uncomplicated courses can be treated as an
outpatient
Hospitalized patients require contact precautions
TREATMENT
Antibiotics shorten the clinical course and reduce the risk of death
MDRST
• Resistant to Ampicillin, chloramphenicol and Bactrim
• Common in the Indian subcontinent
Fluoroquinolones – used as empiric treatment in most parts of the
world
Third generation cephalosporins
Azithromycin
COMPLICATIONS
• Most occur during the second or third week of illness
• Relapse rate is 5-20% even with appropriate treatment
Photo Credit: James Gathany, CDC Public Health Image Library (PHIL # 9258, 2165, 6765) phil.cdc.gov
CASE PRESENTATION: TIMI
8yr old, previously healthy boy presenting with
• 3 days of fever up to 103F, chills, and malaise
• Headache, fatigue, mild abdominal pain
• No vomiting/diarrhea, no confusion, no rash
What else do you want to know?
Exam findings: fever, mild tachycardia, mild hepatosplenomegaly.
Otherwise normal
Born in the US, back from Nigeria 2 weeks ago (went “home to visit
the grandparents”) for the 1st time
DIFFERENTIAL DIAGNOSIS
•
Common viral infections
•
• Influenza, adenovirus, enterovirus
Bacterial infection
•
Travel-related diseases
•
•
•
•
•
Malaria
Dengue fever
Chikungunya
Leptospirosis
Viral hemorrhagic fever (Ebola)
MALARIA
Intra-erythrocytic infection caused by Plasmodium spp.
• Spread by female Anopheles mosquito
• Incubation period as little as 7 days, can be months
Endemic in the tropics, about ½ the world’s population lives in
areas where transmission occurs
• About 207 million cases, 627,000 deaths in 2012
• US: almost 1,700 cases, 6 deaths in 2012, all acquired
through foreign travel
Images from CDC Yellow Book 2016 wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/malaria
DIAGNOSIS
C LINICAL
Classic presentation
• Fever (cyclic?) + chills
• Headache
• Malaise
May also have
•
•
•
•
Myalgias
Abdominal pain
Nausea/vomiting
Cough/dyspnea
L ABORATORY
Gold standard: Peripheral Blood
Smear
• Identify and quantify parasitemia
• Need 3 negatives if high clinical
suspicion
PCR
• Very specific even for low levels of
parasitemia
• Not readily available
Rapid antigen test
• Low sensitivity esp. w/vivax
• Smear as confirmatory test
THE PLOT THICKENS
After you admit Timi to the floor and start anti-malarial medication,
his 4 year old sister Simi shows up in the ED with similar symptoms,
and mom says she “isn’t acting like herself”. While she’s waiting to be
admitted, she has a seizure.
Severe malaria
• Clinical definition: Patients with signs of end-organ involvement,
shock, acidosis, thrombocytopenia, and/or hypoglycemia
• Lab definition: parasitemia >5%
• More common with falciparum
TREATMENT
MALARIA SUBTYPE
DRUG
Uncomplicated Malaria,
P. falciparum or
species unknown
Atovaquone-proguanil
Severe malaria
Artemether-lumefantrine
Intravenous Quinidine gluconate
plus one of the following:
Doxycycline, Tetracycline, or
Clindamycin
For the most up-to-date treatment
recommendations, see the CDC Malaria guidelines
(www.cdc.gov) or call the CDC Malaria Hotline
D ISPOSITION
Admit suspected malaria for 1st
24hrs
• Monitor for signs of severe disease
• Initiate treatment pending species
identification
• Standard isolation
If severe malaria is present, ICU
monitoring is appropriate until
• Parasite load <1%
• Tolerating oral agents
Can discharge if
• No findings of severe disease
• Tolerating PO
ONE LAST CASE
Sonam is a 15 year old female who
presents with fever, chills and fatigue
for the past 3 days.
• Immigrated from Bhutan 13 months
ago
• Healthy since, vaccines are UTD
Blood cultures were sent and she
received a dose of ceftriaxone
• Transferred to your hospital for
admission.
A few hours later, call from the
outside lab: “intra-erythrocyte
inclusions”
Hypnozoite: dormant forms in the
life cycle of certain protozoa that
can lead to “relapse” in infections
• P. vivax and P. ovale almost
exclusively, not reported w/
falciparum
• Primaquine to eradicate
MEET ISABELLA
10 year-old previously healthy female who presents with 2 day history of
high fever, fatigue, headache and rash that started on the chest and spread
to the face. Isabella visited her aunt in Puerto Rico for 2 weeks and
returned last night. Symptoms started yesterday morning. Vaccinations
are up to date.
What is your differential
diagnosis?
Photo Credit: WebMD, available at http://www.webmd.com/skin-problems-and-treatments/ss/slideshow-mosquito-borne-diseases
DIFFERENTIAL DIAGNOSIS
Malaria
Scarlet fever
Roseola
Dengue fever
Typhoid fever
Chikungunya
Leptospirosis
ARTHROPOD-BORNE VIRAL DISEASES
Virus
Aedes aegypti
Dengue 1-4
Chikungunya
X
X
Zika
X
Aedes albopictus
X
X
Photo Credit: James Gathany, CDC Public Health Image Library (PHIL# 9258, 2165) phil.cdc.gov
DENGUE FEVER DISTRIBUTION
Image credit: Bhatt S, et al. Nature 2013
EPIDEMIOLOGY
• Yearly, there are 50-100 million infections and 25,000
deaths worldwide
• Most important mosquito-borne viral disease
• 25% of infected people develop clinical symptoms
• Most severe cases and deaths occur in children
younger than 15 years of age
PATHOGENESIS
• Genus: Flavivirus
• Serotypes (DEN-1, -2, -3, and -4)
• No cross-protection between the serotypes
• Lifetime immunity is obtained only after infection by
each type
• Clinical profile worsens with each infection and
increases the probability of developing DHF and DSS
DEFINITIONS OF DENGUE CLINICAL SYNDROMES
(WHO AND CDC)
1.
Undifferentiated Fever
2.
Dengue Fever
3.
Dengue Hemorrhagic Fever (DHF)
4.
•
5 to 10% symptomatic patients develop severe disease
Dengue Shock Syndrome (DSS)
Case fatality with severe dengue up to 10-20%
Proper case management reduces mortality <1%
CLINICAL PRESENTATION
Live in/travel to endemic area + fever AND 2 or more of the following:
 Anorexia and nausea
 Rash
 Headache
 Retro-orbital pain
 Arthralgia
 Myalgia
Warning signs
 Abdominal
pain/tenderness
 Persistent vomiting
 Liver enlargement >2cm
 Hemorrhagic
manifestations
Comorbidities
 Pregnancy
 Infancy
 Diabetes mellitus
 Coagulopathies
 Lethargy, restlessness
 Positive Tourniquet test
Dengue Fever
Clinical Presentation
Maculopapular Rash
By United States Military https://commons.wikimedia.org/wiki/File%3ADenguerash.JPG via Wikimedia
Commons
Positive Tourniquet Test
“Sunburn rash”
By Ranjan Premaratna,
https://commons.wikimedia.org/wiki/File%3AEarly_Dengue_Fever_Rash_2014.jpg
via Wikimedia Commons
Image credit: Center for Disease Control and Prevention
www.cdc.gov/dengue/training/cme/ccm/page73112.html
LABORATORY WORKUP
CBC + differential
 Leukopenia
 Hemoconcentration
 Thrombocytopenia
CMP




Reactive hepatitis
Electrolytic imbalance
Hypoalbuminemia
Acute renal failure
PT/PTT
 Coagulopathies
 Liver function
Chest x-ray
 Pleural effusion
 Cardiomyopathy
Dengue titers
 PCR, dengue antigen
 Antibodies IgG and IgM
*Always send acute and convalescent
titers
ESTABLISH SEVERITY
Criteria
Dengue
Hemorrhagic Fever
1. Fever
2. Hemorrhagic manifestations
3. Thrombocytopenia
(≤100,000/mcL)
4. Plasma leakage
• Hemoconcentration
• Hemodilution
• Hypoalbuminemia
• Third spacing
Dengue
Shock Syndrome
DHF plus evidence of circulatory failure
manifested by shock OR all of the following:
• Rapid and weak pulse
• Narrow pulse pressure (<20mmHg) or
hypotension for age
• Cold, clammy skin
• Altered mental status
CLINICAL COURSE
Image credit: Dengue Case Management Card www.cdc.gov/Dengue/resources/Dengue%20Case%20Management_card_125085_12x6_Zcard_Dengue.pdf
TREATMENT
• ABCs -> SUPPORTIVE!!!
• Isotonic IV fluid requirement based
on ideal body weight
• Fever is controlled with
Acetaminophen, avoid NSAIDs
• Critical phase: check hematocrit
before each IV fluid change, vital
signs every 1-2hrs and strict
monitoring of intake and output
• Mild cases: home therapy with
adequate fluid intake and bed rest
should be reinforced
Admission Criteria
•
•
•
•
•
•
Severe vomiting
Dehydration
Bleeding
Altered mental status
Clinical deterioration
Evidence of DHF or DSS
(For intensive care)
MEET ERIC
13 year-old previously healthy male who presents with joint aches and
swelling of his feet since 1.5 weeks ago. He returned from a class trip to
India 2 weeks ago. Five days prior to his return, he had a mild “viral”
illness of fever and rash that resolved after 3 days. Vaccinations are up to
date.
Photo credit: www.antimicrobe.org/e48.asp#t3
CHIKUNGUNYA DISTRIBUTION
Image credit: CDC Chikungunya Virus Geographic Distribution www.cdc.gov/chikungunya/geo/index.html
EPIDEMIOLOGY
Over 1 million suspected cases reported in 2014
Large outbreaks with high infection rates (≥30%)
Majority of infected people are symptomatic (72%-97%)
PATHOGENESIS
Genus: Alphavirus
CLINICAL PRESENTATION
Rapid onset of fever and polyarthralgia
 Effusion
 Symmetric
 Severe/ debilitating pain
 Distal joints
Other symptoms
 Rash
 Headache
 Myalgia
 Fatigue
 Nausea/emesis
Children have lower rates of symptomatic disease, and lower case fatality
(<1%)
CHIKUNGUNYA
Image credit: Kalantri, SP 2006
LABORATORY WORKUP
CBC + differential
 Leukopenia
 Normal Hematocrit
 Thrombocytopenia RARE
CMP




Reactive hepatitis RARE
NO Electrolytic imbalance
Normal albumin
Acute renal failure
PT/PTT
 Normal
ESR, CRP
 Elevated
Chikungunya titers
 PCR, Chikungunya antigen
 Antibodies IgG and IgM
*Always send acute and convalescent
titers
TREATMENT
• Symptomatic and supportive care
• Acetaminophen and/or NSAIDs for fever and pain control
• Cold compresses for joint pain
• Steroids NOT indicated
• Avoid Aspirin
• Follow up with subspecialist as needed for sequelae
MEET CLAUDIA
5 yo previously healthy female who presents with 5 day history of
high fever, headache and rash. She also complaints of leg pain with
ambulation. Claudia lives with her family in Hawaii and arrived to
Chicago 6 days ago to visit family. Vaccinations are up to date.
Labs:
WBC 1.5
Hg 15
Hct 45
Plts 26,000
Vital signs:
Alb 2.1
P 156
AST 125
RR 54
ALT 254BP 85/56
Sat: 98% in RA
WHERE DID ZIKA EVEN COME FROM?
Flavivirus (like Dengue, WNV, yellow fever, tick borne encephalitis), spread
by mosquitoes
Transmission
• Can occur before, during, or after symptomatic phase
• In utero
• Sexually transmitted
• Established for contact with an affected male partner
• 1st case report of female-to-male transmission documented in NYC July 15 (MMWR
Early Release Vol. 65)
• Transfusion-related transmission has been reported in Brazil – as yet
unconfirmed
• There have been reports of laboratory-acquired Zika as well
ACTIVE ZIKA TRANSMISSION (AS OF JULY 14)
Image from CDC website. http://www.cdc.gov/zika/geo/active-countries.html
PRESENTATION
Common symptoms
•
•
•
•
May also have
Fever
Rash- typically pruritic, starts on trunk
Joint Pain
Conjunctivitis
• Myalgias
• Headache
Typically mild or asymptomatic (80%) –people often don’t seek care
• Mortality is rare
• Duration: days to 1 week
As far as we can tell, pediatric Zika looks very similar to adult Zika – mild,
self-limited viral illness
• Same appears to go for perinatally-acquired Zika
Infection is thought to confer immunity
IF IT’S SO MILD, WHY ALL THE UPROAR?
IT’S COMPLICATED
Most significant associated morbidity is failure of fetal development
•
•
•
Microcephaly
Impaired growth
Eye, hearing defects
A concurrent spike in the incidence of Guillain-Barré syndrome has been
reported during Zika outbreaks
•
ADEM has also been reported in patients with lab-confirmed Zika
THESE QUESTIONS REMAIN
Which pregnancies are at the highest risk for neurodevelopmental compromise?
•
•
Different risks per trimester?
Does the risk ever become null?*
The likelihood of congenital Zika in a pregnancy with known or potential exposure
Is there increased risk with neonatal Zika infection?
Is it hiding in other vectors we don’t know about?
•
•
Recent locally transmitted case in Utah, no Aedes mosquitos
Found in a different mosquito species in Brazil July 2016: Culex quinquefasciatus
And many more
WHAT’S A PEDIATRICIAN TO DO?
S USPECTED C ONGENITAL Z IKA VIRUS DISEASE
Test serum for Zika RNA
Also test Zika & Dengue IgM,
neutralizing Ab
If obtaining CSF, send these
same tests
Consider pathologic evaluation
of cord & placenta with
appropriate stains, RT-PCR
Test mother for Zika, Dengue
antibodies if not already
done
WHAT’S A PEDIATRICIAN TO DO?
S USPECTED A CUTE Z IKA V IRUS D ISEASE
Test Infants & children with
• Travel to or residence in an affected area in the past 2 weeks
• 2 or more of the common symptoms
If symptomatic <7 days
• Test serum for RNA using rRT-PCR
• If negative, and symptomatic ≥4 days, test serum for Zika and Dengue IgM and
neutralizing bodies
Urine rRT-PCR can be tested up to 14 days after symptom onset
All Zika testing is currently through the CDC; positive tests are reported to the appropriate State Health Department
MANAGEMENT
Acute viral infection is self-limited: supportive care should suffice
For congenital infection:
• Consider additional hearing screen and ophthalmologic
evaluation at 6 and 12mo
• Multidisciplinary developmentally appropriate care
• Neurology
• Developmental-Behavioral Peds
• PT/OT/Speech therapy
CHIKUNGUNYA
“That which bends up”
DENGUE
“Break-bone fever”
Fever
(5-7 days)
Anorexia
Sore throat
Headache
Retro-orbital
pain
Fever
(2-3 days)
Rash
Nausea
Emesis
Myalgia &
arthralgia
(large joints)
Platelets
WBC
Hematocrit
ZIKA
“Overgrown”
Headache
Conjunctivitis
Rash
Rash
Headache
Fever
Myalgia
Nausea
Chronic
arthralgia
(small joints)
Platelets,
WBC
=Hematocrit
Diarrhe
a
Severe
myalgia
Arthralgia
(Edema of
lower
extremities)
Abnormal labs
RARE
LP->Guillian Barré
PREVENTION
Read up on common infectious diseases before
travelling overseas
•
Use appropriate prophylaxis if travelling to a
malaria-endemic area
Repellants containing N,N-diethyl-3methylbenzamide (DEET) in children > 2 months of
age no greater than 30%
Wear protective clothing during mosquito feeding
time (morning and afternoon)
Awareness
Bite prevention
ABCD against
mosquitoborne illness
Bed nets
Eliminate mosquito breeding by covering water
containers and eliminating standing water
Pregnant women, when possible, should avoid travel
to areas with local ZIKV transmission
Chemoprophylaxis
Diagnosis
TAKE AWAYS
International travel is very popular, and increasing each year
• Different exposures→ different infection risks
• Geography, timeline, and symptom complex are key to differential,
workup, & management
• Often hard to distinguish between diseases at presentation
Some infections have crept their way into the US esp. during outbreaks,
so think of exposure to the exposed as well
For infections with treatment options look up current susceptibilities for
the likely area of exposure (CDC Traveler’s Health, your local ID doctors)
BIBLIOGRAPHY & RESOURCES
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