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Traveler with a Traveler with a feverfeverCase presentationCase presentation
Ann SchmidtAnn Schmidt
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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.
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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
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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.
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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.
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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.
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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
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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?
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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.
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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%
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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.
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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%
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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
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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.
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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.
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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
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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
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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
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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
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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
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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.
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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.
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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.
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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.
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Internet SitesInternet Sites
www.malaria.orgwww.malaria.org
www.tripprep.comwww.tripprep.com
www.cdc.www.cdc.govgov
www.istm.orgwww.istm.org
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