Traveler with a Traveler with a feverfeverCase presentationCase presentation

Ann SchmidtAnn Schmidt

CASECASE

68 yo woman presented to the ER with 68 yo woman presented to the ER with several day history of fever and one day several day history of fever and one day history of confusion.history of confusion.

Past Medical HistoryPast Medical History

NIDDM for several years, well controlledNIDDM for several years, well controlled Coronary heart disease with bypass Coronary heart disease with bypass

grafting x 3 one year agografting x 3 one year ago Mild HypertensionMild Hypertension

Social HistorySocial History

Has lived in Madison for >10 years but Has lived in Madison for >10 years but husband and some family members are husband and some family members are still in Nigeria, her home town.still in Nigeria, her home town.

Lives aloneLives alone No petsNo pets NonsmokerNonsmoker Rare Alcohol.Rare Alcohol.

Family HistoryFamily History

Positive for heart disease and diabetes.Positive for heart disease and diabetes. No breast or colon cancerNo breast or colon cancer Family members in the US are healthy.Family members in the US are healthy.

Review of SystemsReview of Systems

Family reports she was well on arrival Family reports she was well on arrival home.home.

No initial fever, chills, sore throat, resp. No initial fever, chills, sore throat, resp. illness or GI symptoms.illness or GI symptoms.

Her first complaint was arthralgias, Her first complaint was arthralgias, followed by fevers to 102 – 105. followed by fevers to 102 – 105.

Mild confusion started on the day of Mild confusion started on the day of admission, worsened by the afternoon.admission, worsened by the afternoon.

ER evaluationER evaluation

Labs – Normal CBC, glucose, Labs – Normal CBC, glucose, electrolytes and BUN/Creatinine.electrolytes and BUN/Creatinine.

Head CT – normalHead CT – normal Chest X-ray – normalChest X-ray – normal Urinalysis – trace ketones, + 2 ProteinUrinalysis – trace ketones, + 2 Protein

Evaluation of fever in the Evaluation of fever in the international travelerinternational traveler

Did they get pre-travel advice?Did they get pre-travel advice? Did they follow the advice?Did they follow the advice? Where did they travel and how?Where did they travel and how? When did they get sick – before they When did they get sick – before they

returned home or several weeks later?returned home or several weeks later?

Incubation periodsIncubation periods

<10 days – Dengue, Traveler’s diarrhea, <10 days – Dengue, Traveler’s diarrhea, Yellow fever, Spotted fevers.Yellow fever, Spotted fevers.

10-21 days – typhoid fever Leptospirosis, 10-21 days – typhoid fever Leptospirosis, Malaria, Typhus Viral hemorrhagic Malaria, Typhus Viral hemorrhagic fevers.fevers.

>21 days – Acute HIV infection, Amebic >21 days – Acute HIV infection, Amebic liver abscess, Malaria, Tuberculosis and liver abscess, Malaria, Tuberculosis and all viral hepatitis.all viral hepatitis.

Most Common Most Common

Malaria is the most common cause of Malaria is the most common cause of fever in the traveler returning from the fever in the traveler returning from the tropics. 27%-42%tropics. 27%-42%

Dengue 8%Dengue 8% Hepatitis 6%Hepatitis 6% Enteric fever 3%Enteric fever 3%

Visiting Friends and Visiting Friends and Relatives ( VFR’s)Relatives ( VFR’s)

Huge problem and the rate of infection is Huge problem and the rate of infection is increasingincreasing

Reason – They do not take the Reason – They do not take the prophylaxis. prophylaxis.

500 million infections, 1 million deaths 500 million infections, 1 million deaths They feel like they are immune from the They feel like they are immune from the

diseases they grew up with.diseases they grew up with.

Who gets Travelers Who gets Travelers malaria?malaria?

VFR’s 23%VFR’s 23% Tourist 12%Tourist 12% Business 9%Business 9% Missionary 11%Missionary 11% Peace Corps 2%Peace Corps 2%

Malaria DeathsMalaria Deaths

1992-2001 4685 malaria cases in US 1992-2001 4685 malaria cases in US citizenscitizens

19% took inappropriate. Drug19% took inappropriate. Drug 56% took nothing56% took nothing In the US about 6 deaths a yearIn the US about 6 deaths a year

Clinical presentationClinical presentation

Fever and influenza symptomsFever and influenza symptoms These symptoms occur at intervals.These symptoms occur at intervals. Some have anemia and jaundice ( think Some have anemia and jaundice ( think

hepatitis)hepatitis) Some have diarrhea ( think travelers Some have diarrhea ( think travelers

diarrhea)diarrhea) As early as 6 days, or months later.As early as 6 days, or months later.

MalariaMalaria

Four types – falciparum, vivax, ovale, Four types – falciparum, vivax, ovale, and malariae.and malariae.

Anopheles mosquitoAnopheles mosquito P. falciparum –the worst – seizures, P. falciparum –the worst – seizures,

mental confusion, kidney failure and mental confusion, kidney failure and coma.coma.

Transmission at dawn and dust.Transmission at dawn and dust.

ChemoprophylaxisChemoprophylaxis

When and where are they at risk for When and where are they at risk for exposure?exposure?

What type of malaria is there?What type of malaria is there? More resistance to falciparum is being More resistance to falciparum is being

reported – Thailand, Burma, and Cambodiareported – Thailand, Burma, and Cambodia

DrugsDrugs

For Chloroquine sensitive areasFor Chloroquine sensitive areas Chloroquine 500 mg tab, once a week Chloroquine 500 mg tab, once a week

starting one week prior and continuing four starting one week prior and continuing four weeks after.weeks after.

May exacerbate psoriasesMay exacerbate psoriases

Chloroquine resistantChloroquine resistant

Mefloquine (Lariam)Mefloquine (Lariam) Falling out of favorFalling out of favor Contraindications – Psych anything, Contraindications – Psych anything,

Epilepsy – decreases seizure threshold, Epilepsy – decreases seizure threshold, Cardiac conduction defectsCardiac conduction defects

250 mg each week250 mg each week

More DrugsMore Drugs

Doxycycline – Low cost but DAILY Doxycycline – Low cost but DAILY dosing.dosing.

Adverse effects – GI upset, vaginal Adverse effects – GI upset, vaginal candidasis, photosensitivity candidasis, photosensitivity

The New Kid on the blockThe New Kid on the block

Malarone – atovaquone 250mg, + Malarone – atovaquone 250mg, + proguanil 100 mg. proguanil 100 mg.

FDA approved July 2000 FDA approved July 2000 Contraindicated with renal impairmentContraindicated with renal impairment Take DAILYTake DAILY EXPENSIVE EXPENSIVE

How to prevent failureHow to prevent failure

My patient had seeked advice – often My patient had seeked advice – often with VFR’s this does not happenwith VFR’s this does not happen

Cost and drug interaction was a problemCost and drug interaction was a problem Patient still travels to Nigeria and only Patient still travels to Nigeria and only

treats herself if she becomes ill. treats herself if she becomes ill. She has now been hospitalized twice for She has now been hospitalized twice for

Malaria.Malaria.

ConclusionConclusion

Talk to patients about travel during the Talk to patients about travel during the physicals or other visits as appropriate.physicals or other visits as appropriate.

Review vaccinations – compare Hep A Review vaccinations – compare Hep A and Hep B to the combined shot.and Hep B to the combined shot.

Modes of travel can be the most Modes of travel can be the most dangerous part of the trip. dangerous part of the trip.

Dr. Stanford’s Bottom Dr. Stanford’s Bottom lineline

If I had 90 seconds and the traveler If I had 90 seconds and the traveler possessed only limited funds, I would possessed only limited funds, I would address :address :

Malaria,Malaria,

Hepatitis A,Hepatitis A,

Seatbelts,Seatbelts,

And condoms.And condoms.

BibliographyBibliography

Lo Re, VL and Gluckman SJ. “Travel Immunizations.” Am Lo Re, VL and Gluckman SJ. “Travel Immunizations.” Am Fam Physician 2004;70(1):89-99, 103-4.Fam Physician 2004;70(1):89-99, 103-4.

Blair JE. “Evaluation of Fever in the International Traveler.” Blair JE. “Evaluation of Fever in the International Traveler.” Postgrad Med, 2004;116(1):13-29.Postgrad Med, 2004;116(1):13-29.

““The Malaria Controversy.” Prescribers Letter Detail The Malaria Controversy.” Prescribers Letter Detail Document 181006.Document 181006.

Centers for Disease Control and Prevention. Health Centers for Disease Control and Prevention. Health Information for the International Traveler 2001-2002. Atlanta: Information for the International Traveler 2001-2002. Atlanta: US Department of Health and Human Services, Public Health US Department of Health and Human Services, Public Health Service, 2001.Service, 2001.

Internet SitesInternet Sites

www.malaria.orgwww.malaria.org

www.tripprep.comwww.tripprep.com

www.cdc.www.cdc.govgov

www.istm.orgwww.istm.org