E048 2-hour Educational Workshop

Seizures and coma in a traveller returning from the tropics

G. Poulakou1 1Attiko University Hospital, Athens, Greece

The physician approaching a returning traveler with coma and probably has to assess thoroughly patient’s history and current clinical status. Patient’s medical history could reveal predisposing factors for particular infections i.e immunosuppressive agents, asplenia etc. Pre-travel history includes pre-departure medical consultation, status and chemoprophylaxis (medications, dosing schedules, compliance). A detailed travel history should include precise dates of travel, arrival & departure from regions with particular endemicity, countries and regions (urban/rural) visited and the relevant climatic conditions, type of accommodation and the prophylactic measures taken (insect repellants, mosquito nets, bottled water). A detailed history of activities should be taken, with focus on freshwater exposure, consumption of street food or diary products, contact with animals. Sexual contacts in the area should be questioned. Incubation period is important to differential diagnosis, whereas exposure to particular vectors/conditions could be the key to the diagnosis. Physical examination should search for signs of meningism, focal neurologic manifestations, skin manifestations and involvement of other organ systems. The diagnostic approach consists of a basic blood work up (CBC, BMP, LFT, urinalysis, blood culture); testing for malaria; central nervous system imaging with CT and/or MRI and targeted investigation for “epidemiologically and clinically compatible” pathogens. The latter category includes serology, PCR, appropriate cultures and/or tissue biopsies with appropriate stains. Management of the patient includes treat of potential life-threatening complications, assessment for neurologic emergencies (status epilepticus, stroke, spinal cord compression) and timely administration of empiric broad-spectrum , antiviral or antiparasitic coverage for very ill patients. Differential diagnosis of the returned traveler with seizures and coma includes malaria, viral /encephalitis, eosinophilic meningitis, and in respect to local epidemiology, tick-borne encephalitis, Japanese encephalitis, yellow fever, dengue, haemorrhagic fever, rickettsial infection, borreliosis, spirochaetosis, parasitic infection. Parasitic infection includes a large array of pathogens and clinical pictures; fever may be less prominent and mass effect with seizures more pronounced. Diagnosis of parasitic infections of the CNS may be facilitated by characteristic imaging features. Within a short incubation period, meningococcal or meningitis should be considered. Tuberculosis has a worldwide distribution and is part of the differential diagnosis as well. Case study: Patient 28 years old returned from a trip in Malaysia, develops a mild upper respiratory infection on day four. He had a full pre-travel consultation, compliant antimalarial prophylaxis and insect protective measures. Fever relapses on day 14 with vomiting, rash, seizures and coma. He developed rapid deterioration in the ICU over the next three days, with haemorrhagic manifestations from skin and CNS, progressive thrombocytopenia and multiorgan failure (renal, liver, heart). The case will be presented in an interactive manner and the final diagnosis will be revealed in the audience.