Returned Traveller

Presentation

• Typically particular syndrome – Fever, respiratory illness, diarrhea, eosinophilia or skin/soft tissue infection
• Over 90% present within 6 months of return aside from Strongyloidiasis and Schistosomiasis
• Most common
  • Travellers diarrhea (80% bacterial)
  • Acute respiratory infections
  • Giardiasis
  • Hepatitis
  • Gonorrhoea

presentation

• Fever
  • DDx
    • Malaria is the most common cause (30%)
    • Typhoid
    • Respiratory infection
    • Hepatitis
    • Diarrhoeal
    • Pyelo
    • Dengue

presentation

• Workup
  • Malaria possible – Thick and thin films (need up to 3 to rule out)
  • Rash – Dengue/rickettsial – Consider doxy
  • Respiratory – Consider influenza and Legionairres/Melioid
  • Fever >7 days and malaria ruled out – Consider typhoid – BC
  • Jaundice – Hepatitis, liver abscess, liver fluke acute cholangitis

fever

• Clues to dengue include short incubation period (4-7 days), maculopapular rash, thrombocytopaenia and leukopaenia

Persistent Diarrhoeal illness

• If diarrhea persists >14 days, bacterial causes are less likely
• Parasite infection is more common but DDx includes lactose intolerance, IBS, coeliac disease and drugs
• Ix
  • Stool MCS/OCP x 3
  • C. diff toxin
  • Strongyloides/amoebiasis/schistosomiasis serology
  • BC
  • Malaria blood films
• If all above negative, consider empirical norflox + tinidazole

eosinophilia

• May be isolated or present with cough, fatigue, skin lesions (urticaria), abdominal discomfort and diarrhea
• The higher the level, the more likely helminth infestations has occurred (strongyloidiasis, filariasis, hookworm, schistosomiasis, cutaneous larva migrans and ascariasis)
• Absence of eosinophilia does not rule out helminth infection
• Need 3 stools for OCP
• Serology for schistosomiasis, strongyloidiasis, filariasis, echinococcus
• Mebendazole empirically once stools collected

Incubation periods

• <10 days
  • Influenza
  • Dengue
  • Yellow fever
  • Paratyphoid
• 10-21 days
  • Malaria
  • Viral haemorrhagic fevers
  • Typhoid
  • Scrub typhus
  • Q fever
  • Borelliosis
  • African trypanosomiasis
• >21 days
  • Malaria
  • Hep A-E
  • Rabies
  • Schistosomiasis
  • Leishmaniasis
  • Amoebic liver abscess
  • TB
  • Brucellosis

history

• Detailed medical history, immunisation history, chemoprophylaxis
• Where, when, what did they do, sleeping arrangements
• Specific food/water exposures
• Sexual exposures
• Needles, tattoos, piercings
• Symptoms of presenting complaint

Initial evaluation

• Key examination
  • Vital signs
  • Rash
  • Lymphadenopathy
  • Hepatosplenomegaly
  • Eschars
  • Scleral icterus
  • Signs of bleeding

Cardinal symptom of fever

• Incubation period <14 days
  • Undifferentiated: Malaria, influenza, dengue, Chikungunya, Scrub typhus, Leptospirosis, Typhoid fever, Acute HIV, Shigellosis, Salmonellosis, Camylobacter
  • Fever with haemorrhage: Dengue, Meningococcaemia, leptospirosis, Crimean-Congo haemorrhagic fever, viral haemorrhagic fever
  • Fever with CNS: Japanese encephalitis, West Nile virus, Murray valley, Dengue, tickborne encephalitis, meningococcaemia, rabies, malaria, poliomyelitis
  • Fever with respiratory: Influenza, SARS, Legionellosis, Q fever
• Incubation 14 days to 6 weeks
  • Malaria, typhoid, HepA/E, schistosomiasis, amoebic liver disease, leptosporosis, Q fever, Acute HIV
• Incubation > 6weeks
  • Malaria, TB, HepB, schistosomiasis

Typhoid fever

• Once malaria ruled out, typhoid is a common cause of febrile illness lasting >10 days
• Vaccination is 75% effective
• Presents with fever, headache, cough, abdominal distension, constipation and prostration
• Can have meningeal signs
• Relative bradycardia is classic 
• Rose spots appear in fair-skinned individuals after several days of fever
• Splenomegaly as disease progresses
• 10% suffer neurological sequelae including psychosis, ataxia, seizures

Typhoid vs. paratyphoid

• Both incubate for 6-30 days
• Not useful to diffn between these = enteric fever
• Fever peaks in evening
• Often confused with malaria
• Best test is BC (50% positive so need to do repeat)
• Bone marrow culture is 80% sensitive but more invasive
• Stool usually negative in first week of illness and serology not definitive

schistosomiasis

• Parasitic blood fluke infection aka Bilharziasis
• Live in freshwater snails, with infectious form entering waterways
• Penetrate human skin and enter bloodstream to the liver where they mature over 2-4 weeks
• Adult worms migrate against flow to mesenteric venules of GI or GU tract
• 3 major species
  • Schistosoma mansoni (intestinal disease)
  • S. japonicum (intestinal disease)
  • S. haematobium (GU disease)
• Prevalence highest in sub-Saharan Africa (+ S. haematobium in middle east)

schistosomiasis

• Chronic infection is the rule with bouts of inflammation induced by egg migration and gradual development of immunity
• In the bowel this leads to ulceration, blood loss and scarring
• In the liver, periportal fibrosis can lead to portal hypertension
• In the bladder, eosinophilic granulomas form with ulceration, pseudopolyps and bladder cancer through chronic inflammation
• Eradication of adult worms in acute or early chronic infection usually leads to complete remission

Schistosomiasis

• Acute infection
  • Swimmer’s itch – Localised dermatitis to cercariae penetration of skin
  • Acute schistosomiasis syndrome (Katayama fever)
    • Seen in non-immune travelers with systemic hypersensitivity reaction within 3-8 weeks of infection
    • Coincides with maximal egg production
    • Sudden fever, urticaria, chills, myalgias, diarrhea, abdominal pain and headache
    • Usually mild and resolving over days to weeks
    • Eosinophilia is almost universal

schistosomiasis

• Chronic infection
  • Usually populations in endemic areas and occasionally travelers to endemic regions
  • Intestinal – Chronic/intermittent abdominal pain, poor appetite, diarrhea, iron deficiency anaemia, chronic ulcerations
  • Hepatosplenic – Portal hypertension secondary to periportal fibrosis
  • Pulmonary – Usually those with hepatosplenic disease with portosystemic collaterals allowing for embolization to lungs
  • Genitourinary – Micro/macroscopic haematuria and/or pyuria classically with terminal haematuria +- haemospermia
    • Eosinophilic granuloma formation, chronic ulceration and increased risk of bladder cancer/pseudopolyps
    • Can result in bladder neck obstruction, hydronephrosis and obstructive kidney failure
  • Neuroschistosomiasis – Can infect spinal cord or brain with obvious dysfunction

schistosomiasis

• Diagnosis
  • Returned travelers – Serology most useful as low egg burden usually
  • Eggs in stool or urine on microscopy
• Treatment
  • Acute schistosomiasis syndrome – Prednisone 50mg daily for 5 days + Praziquantel
  • Chronic infection – Praziquantel

ebola

• 40% case fatality rate in previous epidemic
• Spread via blood or body fluids from infected animal to human and then epidemic begins
• Volume losses cause great morbidity/mortality
• Major haemorrhage less common than once thought
• 2-21 day incubation
• If no symptoms/signs = non-infectious
• Initial fever, fatigue, headache, vomiting, diarrhea, anorexia
• Diffuse erythematous maculopapular rash day 5-7
• Many patients suffer pathological bleeding
• Bloods – Leukopaenia, thrombocytopaenia, transaminitis, DIC if severe
• Diagnosed by PCR

African trypanosomiasis

• Sleeping sickness
• Acute = Trypanosoma brucei rhodesiense
• Chronic = T. brucei gambiense
• Parasitic infection
• Tstese fly vector
• Early infection fever, headache, malaise, arthralgia
• Trypanosomal chancre at 1 week at bite site: Rubbery, painful, 2-5cm lesion
• Lymphadenitis
• Late CNS involvement

Chagas disease

• South American Trypanosoma cruzi
• Major manifestations as Chagas cardiomyopathy and GI disease
• Can be spread vertically
• Acute infection rarely recognized

Yellow fever

• Mosquito-borne viral haemorrhagic fever with high case-fatality rate
• Hepatic dysfunction, renal failure, coagulopathy and shock
• Travellers to Sth America and sub-Saharan Africa
• Symptoms arise 3-6 days post-mosquito bite
• Three stages
  • Period of infection
  • Period of remission
  • Period of intoxication

Yellow fever

• Period of infection
  • Viraemia 3-4 days
  • Febrile, malaise, headache, photophobia, lower back pain, limb pain, myalgia, anorexia, nausea, vomiting, restless, irritability and dizziness
  • Flushed skin, red conjunctiva/gums, epigastric tenderness
  • Hepatomegaly
  • Red tip tongue with white coating in centre
  • Faget’s sign (relative bradycardia)
  • Leukopaenia, relative neutropaenia
  • Transaminitis

Yellow fever

• Period of remission
  • 48 hours
• If abortive infection – resolves here
• Period of intoxication
  • Symptoms return with jaundice, oliguria and bleeding
  • Viraemia resolves and antibodies arise
  • MODS

strongyloidiasis

• Penetration through intact skin from faecally-contaminated soil

Cutaneous larva migrans

• Penetration through skin of larval animal hookworms
• Intense pruritis, lasts years and needs ivermectin

Last Updated on October 2, 2020 by Andrew Crofton