Management of the febrile traveller
Alisdair MacConnachie Consultant Physician in Infectious Diseases and
General Medicine Gartnaval General Hospital
Glasgow
Background
• 1 billion travellers/year worldwide
• Health problems self reported in 22 – 64%
• 8% travellers developing world require medical care
Typhoid
Malaria
Dengue
Leptospirosis Rickettsial disease
Ebola
Lassa
SARS
Avian Influenza Non Infectious
STI
Para typhoid Filariasis
Helminths Amoebiasis
Scistosomiasis Cooccidiomycosis
Histoplasmosis
Melioidosis
Plague Rabies
Q Fever
Tulleraemia
HIV
Learning Outcomes
Following this webinar participants will be able to:
• understand the common causes of fever in returning travellers
• understand the appropriate investigation and management of febrile travellers
• know how to risk assess travellers for Viral haemorrhagic Fever and ensure appropriate care of “high risk” patients
Diagnosis Percentage of all fevered travellers
Percentage hospitalised
Unspecified 22 10
Malaria 21 52
Acute diarrhoea 15 15
Respiratory infection 14 24
Other infections 10 20
Dengue 6 29
Genitourinary infection 4 29
Skin infection 4 21
Non diarrhoeal GI infection
4 45
Enteric fever 2 57
Rickettsial infection 2 20
Ill travellers presenting with fever
Clinical Infectious Diseases 2007;44:1560-1568
NO cases of Viral Haemorrhagic Fever
Imported Malaria in UK 2013
Imported malaria cases by species and region of travel, United Kingdom: 2013
Region of *P.falciparum P.vivax P.ovale P.malariae Mixed 2013
total 2012 total acquisition [1]
Western Africa 826 1 49 21 9 906 730 Middle Africa 106 - 4 5 2 117 66 Eastern Africa 120 6 15 9 - 150 142 Northern Africa 28 - - 2 - 30 32 Southern Africa 1 - - - - 1 7
Africa - unspecified 24 - 4 1 - 29 21
Southern Asia 6 134 - - - 140 221 South-Eastern Asia 1 4 - - - 5 3 Western Asia - 1 - - - 1 1 Eastern Asia - - - - - - 1 South America 1 7 - - - 8 3 Oceania 1 2 - - - 3 4 Cryptic 2 - - - - 2 - Not stated 76 24 6 1 2 109 147 Total 1192 179 78 39 13 1501 1378
Downloaded from; https://www.gov.uk/government/publications/imported-malaria-in-the-uk-statistics
60% of our imported malaria comes from West Africa
Viral Haemorrhagic Fever • Lassa, Ebola/Marburg, CCHF, SAVHFs, RVF, DHF, Yellow fever
Exposure Rural > Urban Nosocomial
Downloaded from; https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/354636/VHF_Africa_2014_update.jpg
Clinical Presentation
Non specific febrile illness
Haemorrhagic manifestations
Sepsis syndrome/shock
Death
Exposure
Up to 21 days
Treatment Supportive
Correct coagulopathy/anaemia ?Ribavirin
So, in febrile returning travellers…
• VHF presents with a non specific febrile illness similar to malaria, enteric fever, Dengue etc
• Malaria and other infections are far more likely and can be fatal if not treated in a timely manner ………we need a rational approach
16 year old Scottish female. Returned on flight to Glasgow via London from Malawi 2 months volunteer work and holiday in Blantyre, building school and playing with local children. Took antimalarial (Malarone) “religiously” Pre travel advice with vaccination against HAV/Typhoid/rabies/HBV Had developed fever, headache, myalgia, sore throat on flight. Collected from airport and brought straight to A&E by mother.
On Examination Temp 38.6⁰C; Pulse 102/min; BP 126/82; Resp rate 22/min; SpO2 99% on air Throat NAD No cervical adenopathy Chest clear and normal chest X ray Abdomen soft, mild generalised tenderness
48 year old Scottish male. Returned on flight to Glasgow from Mumbai (via Dubai) 6 days ago. 6 week trip to Mumbai to visit friends and relatives. Stayed in Mumbai only. Drank “only bottled water”. No Pre travel advice. No pre travel vaccines and no antimalarial chemoprophylaxis. Has a 48 hr history of fever, rigors, headache, myalgia and abdominal pain. No loose stool. Self referral to A&E.
On Examination Temp 38.1⁰C; Pulse 110/min; BP 89/62; Resp rate 28/min; SpO2 99% on air Throat NAD No cervical adenopathy Heart sounds pure Chest clear and normal chest X ray Abdomen soft, mild generalised tenderness
Management Patient is septic!
•IV fluids •Oxygen •All bloods including 2 sets blood cultures and malaria antigen/film
Discussed with local Infectious Diseases •In the abscence of localising signs and fact that travel to India, Typhoid (enteric fever) most likely diagnosis •Commences on 2g Ceftriaxone daily •Transferred to ID ward
Progress Malaria antigen x2 negative FBC shows neutrophilia with thrombocytopenia Biochemistry shows slight hepatitic changes Patient continues to be febrile 48 hrs later when blood cultures reported as growing “gram negative rods” Day 3 of admission confirmed as growing S. typhi Day 4 of admission fever settles – completes 14 days iv Ceftriaxone via OPAT
30 year old male form Sierra Leone. Presents with fever and myalgia 48 hrs after arriving in UK. No localising symptoms on further history. No past medical history and on no regular medications. Lives in Freetown in Sierra Leone and is an athlete. No rural travel, no hospitalisation and no ill contacts in the last 3 weeks.
On Examination Temp 37.9⁰C; Pulse 110/min; BP 96/52; Resp rate 21/min; SpO2 99% on air Throat NAD No cervical adenopathy Heart sounds pure Chest clear and normal chest X ray Abdomen soft and non tender.
Management Patient is discussed with ID
•Urgent malaria film (discussed with haematology) •Blood cultures and “standard bloods” •Transfer ID unit •iv fluids •Ceftriaxone and po Doxycicline
Patient managed in side room with standard infection control •Malaria antigen and film negative •VHF screen carried out due to “concern” •Patient settles with resolution of SIRS •Blood cultures negative •Discharged day 3 with negative VHF screen
29 year old male returned from trip to DR Congo. Travels home by private transport. Wife was concerned that he looks unwell, calls 999 ambulance
1st 2nd 3rd 4th 5th
00hrs 06 12 18 00 06 12 18 00 06 12 18 00 06 12 18 00 06
Arrives A&E at 1530hrs 5 day history of abdominal pain, fever and D&V which has been blood stained O/E has normal observations (To 36.9; HR 90; BP 120/98; RR18; 98% sat) with epigastric pain. Bloods already taken. Transferred to ID unit.
Bicarb 22 Bilirubin 29 Haem 156 Urea 5.9 AST 6383 HCt 0.44 Creat 72 ALT 2157 Plt 10 Na 141 ALP 209 Neut 1.23 K 4.2 Albumin 35 INR 1.2 Lactate 3.0 CK 864 APPTr 1.9 CRP 32 Malaria Ag Neg Fibrin 1.7
1st 2nd 3rd 4th 5th
00hrs 06 12 18 00 06 12 18 00 06 12 18 00 06 12 18 00 06
Arrives ID Unit ~2130hrs, seen by on call SHO Isolated in negative pressure room after overnight discussion with on call ID consultant, who raises possibility of VHF. PPE – double glove, eye protection, fluid repellent gown, FFP3 face mask Limited staff exposure with a record of all staff in contact. Treated with IV ceftriaxone, po doxycycline, given IV fluids and blood products (2x FFP, 1x plts)
1st 2nd 3rd 4th 5th
00hrs 06 12 18 00 06 12 18 00 06 12 18 00 06 12 18 00 06
Full specialist assessment in ID Unit: 3/52 trip to DRC: Working as part of team in “aid camp”. Rural setting but denies any animal or tick bite exposure. Numerous unwell contacts in course of work as a nurse. Unwell for 5 days with multiple symptoms (myalgia, loose bloody stool, haematemesis and haemoptysis , cramping upper abdominal pain, cough, headache) feels has worsened over this time. O/E has petechea, one spontaneous haematoma over left tibia, and several large haematomas from venepuncture sites. Mucosa are clear apart from conjunctival suffusion. Diffuse tender upper abdomen but no organomegaly. Now pyrexial but haemodynamically stable with GCS 15/15.
Formally assessed for VHF risk by 2014 DOH guidelines “ high possibility of VHF”
Samples (blood, urine) dispatched to HPA Porton Patient is increasingly drowsy, but easily roused to GCS 15
1st 2nd 3rd 4th 5th
00hrs 06 12 18 00 06 12 18 00 06 12 18 00 06 12 18 00 06
Positive Ebola PCR result telephoned from HPA Porton at 0100am. Discussions with high security ID unit (Royal Free) about transfer
1st 2nd 3rd 4th 5th
00hrs 06 12 18 00 06 12 18 00 06 12 18 00 06 12 18 00 06
Marked clinical deterioration from 0300am: Worsening confusion, agitation and labile GCS Haematemesis Excessive bleeding from venous access sites Now oozing haemorrhage from gums Problems with IV access Rising heart rate, but BP and RR stable U/O not measurable On-going blood product administration Ongoing discussions about transfer to Royal Free
1st 2nd 3rd 4th 5th
00hrs 06 12 18 00 06 12 18 00 06 12 18 00 06 12 18 00 06
By 1000am is increasingly unwell, now with HR 140; RR 28; GCS 9/15. Given sedation to allow better IV access and more aggressive fluid management . Dedicated blood gas analysis machine provided: finds venous lactate is 19, glucose is 1.7. Hypoglycaemia corrected and on-going blood products. Transfer team ready to move to Royal Free.
1st 2nd 3rd 4th 5th
00hrs 06 12 18 00 06 12 18 00 06 12 18 00 06 12 18 00 06
Transferred by RAF to Royal Free high security isolation unit at 0500am.
1st 2nd 3rd 4th 5th
00hrs 06 12 18 00 06 12 18 00 06 12 18 00 06 12 18 00 06
Died in isolation unit despite on-going supportive therapy; profoundly suppressed GCS (?IC haemorrhage), T1RF with massive pulmonary haemorrhage , MOF.
1st 2nd 3rd 4th 5th
00hrs 06 12 18 00 06 12 18 00 06 12 18 00 06 12 18 00 06
Massive environmental contamination
Use of “High Risk” infection control procedures
No secondary cases