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Workshop Aachen 17-18/11/2017Euregio meeting.

Filip Moerman.Indian fever

Mr S• 28 year old HIV+ Indian man returned from India

(lives and works in Belgium as a cook) 5 days ago. Increasing fever since 7 days. Feels quite sick! Family says: “becomes slow”/Duration of stay in India: 6 wks

• Presented in 3 different emergency units (1 Indian, 2 Belgian), each time ‘internal med specialists’ were looking for OI (latest CD4 = 225/mm³; VL < 400; on DRV/CBC/TAF/FTC).

• Other symptoms/signs: cough, tachypnee, temp = 40.3°c, confused, bradyphrenic, constipated (H/O diarrhea before) , does neither eat nor drink.

Paraclinical exams• CRP = 458 mg/l• Hepatomegaly and esp splenomegaly on US• TGP, TGO, Bilirubin, LDH and gamma-GT all ↑• Creat = 2,3 mg/dl, oliguria• WBC = 1850/mm³• Platelets = 28.000/mm³• Hb = 9.1 g/dl• CT brain = nl (no MRI at the time of admission)• LP: ‘clear’, analysis ‘en cours’.

What do you think?• What did we do?

• Treatment ‘empirically’?

• What would you do?

Fever ‘after tropics’: general approach• RULE OUT the 3 major killers• Detailed travel history + clinical exam• IF NEG: start Doxycycline and perform thorough

blood analysis (eosinophilia!)• Doxy treats all tick bite fevers (mainly rickettsiae),

Borrelioses, Syphilis, Q-fever, Leptospirosis,…• If Eosinophilia present: quantify (Very high =

Schistosomiasis, Filariasis, Strongyloidiasis, Trichinosis, Fasciolasis); less high (loeffler, …)

In detail: the three killers; in overview: other causes (remember

Doxy!).• Exclude IMMEDIATELY three life dangerous

infections: Malaria, Typhoid fever (vacc +/-), Amoebic abcess of the liver. Via blood slide, Haemocult, US.

• If negative: think epidemiologically and geographically; look at other symptoms.

• DD: katayama, trypanosomiasis, diarrhea + fever, TBC, HIV, African tick bite fever e.a. rickettsiosen (cfr Southern Europe!), borrelioses, kala azar, dengue, virushepatitis (vacc!), brucellose, worms/loeffler, cosmopolitan diseases (EBV, CMV, Syphilis)

• Good Website for DD = www.fevertravel.ch

Typhoid feverIn general

– Salmonella typhi (Daniel Salmon, syn. Eberth’s bacillus)– New name : Salmonella enterica serotype typhi– Salmonella paratyphi A, B, C– Humans are the reservoir for S. typhi – ≠ Spotted Typhus (= Rickettsia)

Clinically

• Big variability, unfortunately rather non-specific: THINK

ABOUT IT!

• Incubation 7-14 days (long!) (range 3-60 j)

• Septicaemia ‘

• Fever that increases gradually for 5-8 d, than stagnating

• Dry cough often present (cfr malaria)

• Sick patient, headache “URTI, LRTI, flu-like, malaria”

• Abdominal pains, diarrhea, constipation (!), vomiting,

becoming typhoid

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Clinically • INCREASING fever

• +/- Hepatosplenomegalie

• Roseola typhosa (not often)

• Relative bradycardia (Faget’s sign)

• Asymptomatic ECG changes

• Typhoid : confusion

• Spontaneous abortion

• Sometimes massive hair loss

Improvement after week 3

Clinically (2)• Perforation of terminal ileum (late)

peritonitis (pathognom, buttoo late)

• Internal bleeding

• Abcess formation

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Typhoid : classical complication is perforation terminal ileum

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Important complications of Typhoid Fever

Abdominal• Gastrointestinal perforation• Gastrointestinal bleeding• Hepatitis• Cholecystitis (usually subclinal)

Cardiovascular• Myocarditis (3%)• Shock

Other• Focal abscess• Pharyngitis• Miscarriage

Neuropsychiatric• Encephalopathy• Delirium• Psychotic states• Meningitis• Impairment of coordination

Respiratory• Bronchitis• Pneumonia• Hematologic• Anemia• DIC (usually subclinical)

Diagnosis• Non specific clinical picture, but default diagnosis• Perforation of ileum = pathognomonic but too late of course.

• Cultures : blood (!), stool, urine, bone marrow (gold standard)

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Treatment (mind the slow response!)

• Chloramphenicol : cheap• Quinolones : ofloxacine, ciprofloxacine excellent, minimum 10 days: RESIST ↑• Cephalosporines : ceftriaxone excellent (Asia!)• Azithromycine works but bacteriostatic• Ampi, amoxy, cotrimoxazole : resistant!

• Resistance especially in Asia; Nepal, India!• Laparatomy if perforation • ? Dexamethasone 3 mg/kg QDS, total of 8 doses

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CarriersGall bladder stones and Schistosomiasis infection :

• Cholecystectomy followed by AB• Praziquantel if Schistosoma haematobium before AB

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Typhoid Mary • Irish woman (1869-1938)• Emigration USA in 1883• 1906 : Cook for wealthy banker Charles Henry Warren (Oyster Bay)• 6 out of 11 people fell ill (Mrs Warren, 2 daughters, 2 maids, gardener)

– 3 weeks later Mary leaves• George Soper (sanitary engineer) is hired

– Family had changed cooks 3 weeks before outbreak– Soper tracked Mary down and demanded urine, faeces and blood sample– “…it did not take Mary long to react to this suggestion. She seized a carving fork and

advanced in my direction. I passed rapidly down the narrow hall, through the iron gate…”

Mary Mallon

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Typhoid Mary• Within the previous 10 years, Mary had worked for 8 families• Seven of them had typhoid outbreaks• 22 people fell ill and 1 died• 1907 : arrest : positive confirmation (stool culture)• Isolation x 3 years at Riverside Hospital (North Brother Island, East River)• 1910 : released and vanished• Pseudonym Mrs Brown : cook in Sloane Maternity Hospital (Manhattan)• 25 people ill: doctors, nurses and other staff, 2 died• Send to North Brother Island x 23 years• Same time : 237 other typhoid carriers were supervised.

Prevention

Vaccination : – Typhim®– Vivotif® vaccin oral (live vaccine!)

BUT: protection only 60 à 70%.... during 3 years

HYGIENE…

But above all, remain a happy traveler!