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Fever in the returned traveller (NPS 2/2012) recommended - copy

Manual of Travel Medicine, Australia Dec 2011

see also  http://www2.ncid.cdc.gov/travel/yb/utils/ybBrowseO.asp

INVESTIGATING THE RETURNED TRAVELLER  - Summary (Full sheet)

Assess Risk

  • Africa - schistosomiasis
  • Africa, PNG, Solomon Islands, Vanuatu - Malaria
  • Exposure risk - contaminated food & water, insect bites, sexual contacts
  • Risk increases with length of stay, remote area travellers & Backpackers

Febrile Illness - refer immediately if unwell

  1. Malaria until proven otherwise
  2. Typhoid Fever & Dysentery
  3. Viral Hepatitis ( A to E )
  4. Dengue
  5. Others: pneumonia, legionnaires, septicaemia (meningococcal, staph, strep, meliodosis)
    gonorrhoea, chlamydia, leptospirosis, Q fever, typhus, acute HIV.

Investigations:

  • Thick and Thin Blood films 12 hrly x 3 - one negative blood film does not exclude malaria
  • If thrombocytopaenia there is a high chance of malaria - refer immediately

Diarrhoeal Illness - (NB. could still be malaria)

  • Bacterial - Enterotoxigenic E. coli (ETEC) account for >80% of cases, Less common - Campylobacter, Salmonella, Shigella, Yersinia, Aeromonas
    - Single Faeces M & C usually will detect these (Nb. ETEC not detected with routine culture)
    - Treat Norfloxacin 800mg stat then 400mg BD for 3 days or Azithromycin (To hospital if unwell)
  • Parasites - Giardia most frequent (Treat with Tinidazole 2 g orally stat)
    Less common but important: - Entamoeba histolytica, Hookworm, Strongyloides, Schistosomiasis, Cryptosporidium, Clostridium difficile and Vibrio cholera (especially if watery diarrhoea).
    - Stools M & C x 3 (ask for microscopy for tropical parasites - should also include immunoassay for Giardia & Crytosporidium antigens)
    - Persisting diarrhoea: collection of faeces using preservative may detect D.fragilis parasite
    - FBE may show eosinophilia (NB. giardia, amoebae and helminths (tapeworms, adult ascaris) DO NOT cause eosinophilia.)
  • Treatment
    consider empirical therapy according to exposure
    - mebendazole 100mg BD 3 days - roundworm.
    - praziquantel - schistosomiasis, fasciola (drug is easy and safe to use).
    - Albendazole,: - ascaris,hookworm, strongyloides (drug has high toxicity; therefore pursue diagnosis actively).
    - Ivermectim - onchocerciasis & strongyloides
    - Tinidazole 2g daily 3 days (amoebic dysentery) or metronidazole 400mg three times a day for 10 days. cure rate > 95%
      For cyst carriers add diloxanide furonate 500mg three times a day for 10 days after metronidazole.

Schistosomiasis - An increasing illness amongst travellers & often asymptomatic

  • Geography: - North & Central Africa particularly Sub-Saharan Africa
    - Egypt & Gulf states (Saudia Arabia, Iran, Iraq, Syria, Turkey)
    - India, China, Indonesia, Philippines, Thailand, Cambodia, Laos, Japan
    - South America
  • Symptoms: - Acute febrile illness (Katayama Fever) often with urticarial rash.
    - Cercarial Dermatitis ( a common self limiting illness with itchy papules lasting a few days - symptomatic treatment only is required.)
    - Chronic Fibro inflammatory disease occurs after many years if untreated.
  • Investigations: - Serology for all returned travellers from Africa and other risk areas who swam, waded or walked in streams or lakes. Schistosoma eggs can be ingested via contaminated water.
    - Check for Eosinophilia.
    - Other tests include Faeces for eggs & Terminal urine x 3 for microscopy
    nb. Serolgy is often negative with the early Katamaya fever and eggs do not appear until weeks later.
  • Consider Empirical treatment:
  • Treatment: Praziquantel 40mg/kg/d for 3 days gives 95% cure rate with no relapses. Eosinophilia often takes 6 months to reduce and may actually rise soon after treatment.

Serological tests of value

  • Schistosomiasis: early seroconversion within weeks but may be delayed for up to 3 months
    few false negatives after 3 months
    some false positives occur
  • Amoebiasis: highly specific.
    sensitivity:- extra intestinal disease - 95%
    invasive intestinal disease - 85%
    asymptomatic carrier - 10%
  • Strongyloides: sensitivity & specificity - 80-90%
    (in comparison, stool microscopy = 80% sensitive)
  • Filariasis: up to 30% false positives
    low positive results difficult to interpret -Treat: diethyl carbamazine
  • Hydatid: sensitivity:
    active liver cysts 90%
    dead/calcified cysts 50%
    specificity: - poor at low titre IHA
    good at high titre IHA
  • HIV: most positive by 3 months
    if high risk check at 6 & 12 months

Information mostly taken from: "International Travel and Health" (WHO year book - internet only)
Australian Immunisation Handbook, 8th Edition - 9/2003 - Part1 - Part 2 & Part 3 (large pdf files)
Centre for Disease Control, USA -  www.cdc.gov/travel Travel Health Seminar Oct 96, June 97,Feb 98, March 99, May 2000, August 2002 & March 2005 - Victorian Medical Postgraduate Foundation.
Manual of Travel Medicine, Melbourne, Oct 2004. Updated 06/09/2006.  Additional references & disclaimer.

 

 

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