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Management of the febrile traveller Alisdair MacConnachie Consultant Physician in Infectious Diseases and General Medicine Gartnaval General Hospital Glasgow
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Management of the febrile traveller

Alisdair MacConnachie Consultant Physician in Infectious Diseases and

General Medicine Gartnaval General Hospital

Glasgow

INTRODUCTION

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

Ebola!

HPS Weekly Report 13th August 2014

How do we risk assess for VHF?

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

What illnesses do travellers get?

New England Journal of Medicine 2006;354:119-130

New England Journal of Medicine 2006;354:119-130

New England Journal of Medicine 2006;354:119-130

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

Downloaded from; http://www.who.int/csr/disease/crimean_congoHF/Global_CCHFRisk_20080918.png?ua=1

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

CASE 1

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

Could this be VHF?

Malaria RDT positive

Falciparum ring forms 2% parasitaemia

CASE 2

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

CASE 3

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

CASE 4

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

Presenter
Presentation Notes
Total 6 plts; 6 FFP; 2 cryo; 2 PRCS

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

Summary

• VHF has a non specific presentation • Implications for clinical and laboratory staff • The algorithm works – use it • Speak to your local Infectious Diseases clinicians

• Keep the risk of VHF in context • Common community acquired infection • Malaria • Enteric fever • Dengue fever


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