Emergency Department Evaluation and Management of the Febrile Traveler

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  This presentation, intended for emergency medicine residents, covers the evaluation and management of four common causes of fever in the international traveler: malaria, typhoid, dengue and chikungunya.
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  • 1. Fever in the International Traveler Resident Conference Joseph M Reardon, MD
  • 2. Disclosure Statement • No financial conflicts of interest to disclose. Special Thanks • Paul Lantos, MD
  • 3. Your best friend for travel medicine:
  • 4. Color Codes •Red = Core EM Content •Black = All the fun stuff
  • 5. Background: Travel Medicine • 100,000 international travelers per year • 50,000 have a health problem while traveling • 8,000 will see a physician • 1,100 will be incapacitated (i.e., our patients) ISTM
  • 6. Case • PWR • 45y M • No PMH • 3d fever to 102F, chills, sweats • Mild generalized HA • NBNB emesis x1 • Malaise • ROS otherwise negative collider.com
  • 7. Travel Screening !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
  • 8. Guinea-Bissau: 0 cases Guinea: 2,871 cases
  • 9. Approach to Febrile Traveler • Travel History • Countries • Dates • Setting (urban vs rural) • Contacts • Vaccination Status • S/Sx • ROS PLOS Neglected Tropical Diseases
  • 10. Differential Diagnosis
  • 11. Malaria
  • 12. Malaria: Location 300-500 million infections/yr; 2.5 million deaths/yr
  • 13. Malaria: Life Cycle
  • 14. Malaria: Causative agent CDC
  • 15. Malaria: Risk Factors ISTM • Travel to Africa: • 2.4% risk per month in West Africa • 1.5% risk per month in East Africa • Mosquito exposure (Anopheles gambiae vs Anopheles quadrangulatus) • Day biting (Haiti, much of Latin America) vs • Night biting (Africa) • 90% of reported cases in travelers had symptom onset after return to North America
  • 16. Malaria: Symptoms • Cyclical fever / chills / sweats • (often absent for falciparum, variable for others) • Tachycardia, tachypnea • Headache • Cough • Nausea / vomiting / abdominal pain / diarrhea / anorexia • Arthralgias / myalgias • Initial symptoms are often misleading! WHO
  • 17. • Vitals • Skin: • Jaundice • +/- anemia • Splenomegaly (more common after several days) • Hepatomegaly Malaria: Physical Exam
  • 18. • CBC: normochromic, normocytic anemia, thrombocytopenia • CMP: hypoglycemia, mild transaminitis • Coags • T&S • Rapid test • Giemsa Stain: thick and thin smears • UA • CXR • CT Abd if splenic infarct is suspected • NOTE: RPR and VDRL may be falsely positive! Malaria: Diagnostic Testing Binax
  • 19. Malaria: Treatment • By region: • Chloroquine-sensitive regions (including Mexico): chloroquine • Nonendemic areas (i.e., short-term travelers): atovaquone-proguanil (Malarone) or mefloquine (contraindicated in Long QT) • Alternative: primaquine (but must test for G6PD first to avoid fatal hemolysis!!) • Endemic areas (i.e., long-term travelers / native residents): Artemisinin combination therapy (ex: Artemether-lumefantrine [Coartem]) • Supportive care (fluids, antipyretics, antiemetics) • Consider exchange transfusion if signs of end-organ damage First Aid
  • 20. • Diagnoses of complicated malaria must be admitted to ICU • AMS, seizures • Respiratory / circulatory collapse • Metabolic acidosis • Renal failure, hemoglobinuria, jaundice (blackwater fever) • Hepatic failure • Coagulopathy, DIC • Severe anemia (>5% of RBCs with parasites, OR >100,000 parasites / mcL) • Hypoglycemia • Pregnant patient: high risk for placental malaria Malaria: Critical Actions
  • 21. Typhoid
  • 22. Typhoid: Location Frontiersoftravel.com
  • 23. Typhoid: Life Cycle Causes: • Salmonella typhi Typhoid • Salmonella paratyphi  Paratyphoid (types A, B & C) • A & B are indistinguishable from typhoid • C has different symptomatology
  • 24. Typhoid: History and Physical Exam • Week 1: (in unvaccinated) • Gradually rising (“stepwise”) fever, chills, without rigors • Relative bradycardia • Diarrhea OR constipation • Headache • Week 2: • Abd pain • “Rose spots” (faint salmon-colored macules on trunk & abdomen) • Week 3: • Intestinal bleeding • Intestinal perforation, sepsis, peritonitis • Septic shock (15% of cases) • AMS (17% of cases) • DIC, pneumonia, meningitis, myocarditis, renal failure Lisa See
  • 25. Typhoid: Diagnostic Testing • CBC • CMP • Coags • Stool culture (30% sensitive but very specific) • Blood cultures x2 (70% sensitive but very specific) • The floor may obtain bone marrow culture (gold standard) or ELISA
  • 26. Typhoid: Treatment • Patients from Asia: azithro • Rest of the world: Cipro • Alternative: ceftriaxone 2g IV/IM x 2 wks • Recognize need for blood transfusion HippoEM
  • 27. Typhoid: Critical Actions • Recognize life-threatening complications: • Typhoid encephalopathy: AMS (17% of pts) • Treatment: dexamethasone • Intestinal perforation (more common in small bowel) (10-25% of pts) • DIC Tintinalli
  • 28. Dengue Virology.wisc.edu
  • 29. Dengue: Location WHO 100 million infections/yr; 25,000 deaths/yr
  • 30. Dengue: Life Cycle Oxitec.com Singapore MOH Four serotypes Arbovirus (=Arthropod-borne virus)
  • 31. Dengue: Symptoms • “breakbone fever” x 5-7d • sometimes biphasic fever with a second 1-2d period • Myalgias, arthralgias • Retroorbital HA • N/V (1/2 of pts), diarrhea (1/3 of pts) • Dry cough, sore throat, congestion (1/3 of pts) • More likely asymptomatic in children First Aid
  • 32. Dengue: Physical Exam • “Dengue facies” with facial edema • Fever • Nonspecific exam • Pale, morbilliform rash in ½ of pts • Spreads from trunk outward to extremities/face • Up to ½ of pts with: • Conjunctival injection • Pharyngeal erythema • Lymphadenopathy • Hepatomegaly UTD
  • 33. Dengue: Diagnostic Testing • Dengue ELISA • CBC • Leukopenia is specific to the diagnosis • Thrombocytopenia <100k in most pts • CMP • Mild AST elevation (2-5 times upper limit of normal) • T&S • Fibrinogen
  • 34. Dengue: Critical Actions • Diagnosing Dengue Hemorrhagic Fever • Typically an autoimmune-mediated phenomenon in patients with prior dengue infection • Four cardinal features: • Hemoconcentration (Hct >20% above baseline) • Plt <100k • Fever x2-7d • Hemorrhage • Positive tourniquet test • Spontaneous bleeding • Require ICU admission • Shock of septic & hemorrhagic origin • 50% mortality without care; <5% mortality with care First Aid
  • 35. Tourniquet Test • 6:27-6:37 • Inflate BP cuff to MAP x 5 mins • Inspect for petechiae CDC
  • 36. Dengue: Treatment • Fever management with APAP • Avoid aspirin and NSAIDs due to bleeding risk • DIC Management • Aggressive fluid resuscitation for vascular permeability • No indication for steroids, antivirals, etc. Williams’ Hematology
  • 37. …AND??? …AND??? Fever + Headache in a traveler = Malaria, dengue, meningitis…
  • 38. Chikungunya Virus CDC
  • 39. Chiku-what???
  • 40. Chikungunya: Location NYTimes.com 2nd most common arbovirus in travelers, after Dengue
  • 41. Chikungunya: Life Cycle PLOS Neglected Tropical Diseases
  • 42. • High fever x3-5d • Symmetrical (70%) polyarthralgia, primarily distal (60%) • Occasionally, meningoencephalitis • Rarely, ascending paralysis & Guillain-Barré Chikungunya: Symptoms Tintinalli
  • 43. Chikungunya: Physical Exam • Periarticular edema • Rash starting after 3d starting peripherally Intl Congress on Infectious Diseases
  • 44. Chikungunya: Diagnosis • Chikungunya IgM ELISA • PCR • CBC • CMP • EKG • Consider LP to r/o alternative cause of neurologic manifestation • No quick diagnostic mechanism! Tintinalli
  • 45. Chikungunya: Treatment • NSAIDs once dengue fever is ruled out • Ribavirin for severe cases • Interferon-alpha for severe cases • Chloroquine may reduce long-term arthralgias (but is not recommended by most recent studies) Tintinalli
  • 46. Chikungunya: Red Flags • Meningoencephalitis is most common neurologic complication • Respiratory failure • Myocarditis • Shock • 5-30% of patients will have chronic arthropathy • Severe complications are rare.
  • 47. N. Meningitidis Serotype A BioQuell
  • 48. Neisseria meningitidis Serotype A: Location Natl Healthcare Travel Network & Centre
  • 49. Neisseria meningitidis Serotype A: Pearls • Slightly different serotype from N. meningitidis in the United States, which contributes to its high transmissibility • Is preventable with Menactra and Menveo vaccines • A new vaccine is being developed specifically targeted for the African strain • Treat similarly to US-acquired meningitis: • Ceftriaxone admit to monitored setting • Strains generally respond to ceftriaxone and even penicillin G!
  • 50. Comparison Agent P. falciparum S. typhi Dengue virus Chikungunya Location Tropics Tropics Tropics Africa,Asia,Euro,Carr ibbean Key Symptoms Cyclic fever Abd pain, IBS-like symptoms Retroorbital HA Polyarthralgias, rash Exam Findings Splenomegaly Rose spots Petechiae Edema, rash Diagnosis Giemsa BCx, Stool Cx Coaguloathy, ELISA Transaminitis, ELISA Treatment Chloroquine, atovaquone, artemisinin Azithro (Asia), Cipro (everyone else) Supportive, transfusion Supportive, ribavirin, interferon Red Flags Cerebral malaria, Placental malaria Encephalopathy, intestinal perf Dengue Hemorrhagic Fever Meningoencephalitis
  • 51. Practice questions! A 4-year-old female Brazilian immigrant presents with fatigue and abdominal pain with temperature to 104F. She appears acutely ill. She is tachycardic and tachypneic with hepatomegaly; there is no rash or indication of joint pain. Test results include: Tbili 4.9, AST 236, ALT 247. RUQ ultrasound demonstrates an enlarged liver. • Which would confirm the diagnosis? • Viral hepatitis panel • Blood smear • Leptospirosis microscopic agglutination test • Stool O&P Modified from PEER
  • 52. Practice questions! A 27-year-old male backpacker presents with diffuse macular erythrodermal rash, blood pressure 85/37, temperature 102F. Lab tests reveal elevated transaminases and creatinine, and Plt of 86K. He recently returned from Guatemala and states that he developed a persistent nosebleed while hiking 1 week ago. He still has packing in both nostrils. • What is the most likely causative agent? • Rickettsia prowazekii • Dengue virus • Staphylococcus aureus • Yersinia pestis Modified from PEER
  • 53. Practice questions! A 24-year-old man presents with high fever to 106F, confusion, swelling of the wrists and ankles, and weakness of the bilateral lower extremities. He recently traveled to Democratic Republic of Congo and received all recommended vaccinations prior to travel. Which of the following is most likely to reduce the risk of neurologic complication? • Ice packs and intravenous ketorolac 30mg Q6H • Ice packs, intravenous acetaminophen, and await serologic testing • Lumbar puncture and therapeutic CSF removal • Intravenous piperacillin/tazobactam • Intravenous methylprednisolone
  • 54. Practice questions! A 39-year-old woman presents with confusion, mild headache, generalized myalgias, and morbiliform rash in the setting of 2 weeks of low-grade fever. She returned from Peru last week. She has been constipated since she returned home, which she attributes to no longer eating vegetables from roadside stands. Which of the following is most important to prevent serious neurologic complication? • Intravenous azithromycin • Intravenous ciprofloxacin and dexamethasone • Intravenous vancomycin and piperacillin/tazobactam • Intravenous acyclovir
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