Travel Medicine

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    Introduction

    • Prevention
      • Pre-travel advice about preventable infections
      • Prophylaxis
      • Immunization
      • Behavioural practices to minimize exposure.
    • Treatment

     

    • Common Travel-Associated Infections

      Febrile illnesses

      Malaria

      Dengue fever

      Typhoid fever

      Rickettsial infection

      Yellow fever

      Mononucleosis syndrome (cytomegalovirus and Epstein-Barr virus)

      Brucellosis

      Travelers' diarrhea

      Bacterial agents: Escherichia coli, Campylobacter, Salmonella, and Shigella species

      Viral agents: rotavirus

      Protozoa: Cryptosporidium, microsporidia, Giardia, and Isospora species

     

    Fever in Returning Traveller

    • CBC+diff, liver panel, Cr. LDH, glycemia, electrolytes, CRP
    • thick/thin smear x3q8-12h.
    • Blood cultures.
    • G6PD (allows some drugs to be used)

     

    Chikungunya

    • 1-12 days o incubation, usually 3-7 days
    • Severe arthralgia, back pain, myalgia, high fever, conjunctivitis
    • This usually improves over 2-3 days and is followed by the onset of a generalized maculopapular rash.  Fever may occur after a break of 1-2 days.
    • Petechiae, gum bleeding, positive tourniquet test can be seen.
    • 5-10% can remain having arthralgias, arthritis for months to years.
    • W/u:
      • Follow platelets, hematocrit
      • Malaria, Dengue, Chikungunia PCR and other serologies.
    • NO SPECIFIC TREATMENT.
      • Observe
      • DO NOT use ASA/Nsaid... can worsen
      • Acetaminophen is only accepted analgesic/antipyretic.

     

    Enteric (Typhoid) Fever

    • Salmonela enterica sp.
      • Serotype typhi (salmonella, paratyphi A, etc..)
    • Acquire: fecal flora
    • Penetrate gut mucosa, travel to spleen/liver/bone marrow, not cleared immunologically.
    • Clinical Features
      • Incubation: 10-20 days.  Range 3-56 days.
      • Duration: 4 weeks.
      • First week: headache, malaise, rising remittent fever.
        • Constipation and mild non-productive cough.
      • Second week: toxic, hepatomegaly, high temp sustained.
        • "rose spots" appear in many pts.
    • Feared complication: perforation of bowel. (usually 3rd week or several weeks after).
    • Treatment:
      • Fluoroquinolones or IV 3rd generation cephalosporins for 2 weeks.
      • In Indian subcontinent, high resistance to quinolones, (use cephalosporins).
      • Relapse can occur after initial abx tx. (10%)
      • Usually do stool samples after to ensure eradicated.

     

     

    Stool: C&S: Salmonella, shingella, campylobacter, yersinia.

    Upon request: Hemorrhagic E.coli.

    Stool O/P: Worms, Ova (eggs from worms), Unicellular cysts (entamoeba, giardia), trichrome stain (microsporidium).

                (Many labs have giardia, cryptosporidia antigen testing). 

     

     

    Traveller's Diarrhea

    • Bacterial: ETEC, Campylobacter, Salmonella (not Typhi subtype), Shingella (bloody diarrhea), Vibrio (including V. cholerae o1).
    • Viral: Norovirus, Astrovirus, rotavirus.
    • Parasitic:
      • Risk increaes with duration of diarrheal symptoms.
      • Giardia intestinalis, Entamoeba hystolitica, Cryptosporidium,....
    • Acute non-invasive:
      • Fluoroquinolones, Azithromycin or Rifaximin.
    • Acute-invasive Diarrhea: Fluoroquinolones and Azithromycin.
    • Prolonged Diarrhea; Look for parasitic etiology.

     

    Dengue 

    • Mosquito borne illness (Aedes aegypti - feeds urban environments, daytime)
    • Most prevalent infection in the world
    • Areas
      • Southeast Asia
      • South Pacific
      • South + Central America
      • Carribean
    • Incubation: 4-7 days
    • Symptoms (initial)
      • Some asymptomatic
        OR
      • Acute Febrile Illness
        • Frontal Headache
        • Retro-Orbital Pain
        • Myalgias
        • Arthralgia
      • +/- Spontaneous bleeding (purpura, melena, conjunctival injection) - aka "Dengue Hemorrhagic fever"
    • Symptoms (late)
      • After fever --> Macular or scarlatiniform rash (spare palms+soles)  --> Petechiae on extensor surfaces
    • Labs
      • Low WBC
      • Low Plts
      • Elevated Liver Enzymes
    • Diagnose: --> IgM and IgG or PCR for Dengue
    • Management
      • Conservative (tylenol for fever)
      • Fever resolves in 5-7d
      • Small percentage get second febrile period ("saddleback pattern")
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