Images and data courtesy of Tropical cases
. Mike Brown
. Vicky Johnston
. Tom Doherty Anna Checkley . Caoimhe Nic Fhogartaigh . Maggie Armstrong
. Michael Marks
. & others GP
2
“Classical Tropical Diseases”
Aims Malaria 805 Gnathostomiasis 4 Leishmaniasis 290 Brucellosis 4 Enteric fever 78 Hookworm 3 Common/ important causes of Dengue 48 Post malarial neurological syndr. 2 Hansen’s 41 Dysentery 2 fever/ rash/ diarrhoea Hydatid 36 Madura foot 2 Loa loa 30 Cholera 1 in migrants/ travellers Schistosomiasis 26 Tropical sprue 1 Tick typhus 23 Anisakiasis 1 Amoebiasis 20 Ascariasis 1 Cysticercosis 18 Histoplasmosis 1 Eosinophilia 14 Mansonella 1 Leptospirosis 9 Ciguatera poisoning 1 Strongyloides 9 Parasitophobia 1 Trypanosomiasis 7 Taenia 1 Wuchereria 6 Tropical pulmonary eosinophilia 1 Onchocerciasis 5 Rabies 1 Chikungunya 4 3
“Infectious Diseases” Case 1 Presumed viral illness 716 Empyema 7 Skin sepsis 490 Necrotising fasciitis 4 . 28 years old student . Temperature: 38.6ºC Gastroenteritis 467 Syphilis 4 UTI 390 Nocardia 3 . Pulse: 100 regular Pneumonia 347 Lyme disease 3 . 48 hour history TB 308 Lemierre’s syndrome 3 . . Fever BP: 110/60 Septicaemia 117 Prostatitis 2 Viral illness 112 Yersinia 2 . aching muscles . RR: 20 breaths/min HIV / AIDS 70 Toxoplasmosis 2 . mild headache . Sats: 97% room air Tonsillitis 69 Pelvic Inflammatory Disease 2 . loose bowels Viral hepatitis 68 Infected liver cysts 1 Meningitis 38 Conjunctivitis 1 Abscess 27 Infected miscarriage 1 . Born in Nigeria . CVS, RS, GI, CNS: Infective endocarditis 24 Sporotrichosis 1 Chronic hepatitis C 14 Tetanus 1 . One month trip home to unremarkable visit family Sinusitis 9 Osteomyelitis 9 . Returned 1 week ago
. No malaria prophylaxis ?
1 Differential diagnosis Diagnosis Malaria Virus URTI / influenza arbovirus: dengue, hepatitis A / B /E Acute EBV, CMV HIV seroconversion Bacteria enteric fever gastroenteritis other bacterial sepsis typhus Protozoa amoebic liver abscess
Diagnosis Treatment of severe malaria
Trial Population Mortality: Mortality: p value Artesunate Quinine
SEAQUAMAT Adults 15% 22% 0.0002 SE Asia (107/730) (64/731)
• Subgroup >10% 23% 53% 0.001 parasitaemia (28/121) (57/108)
Thick Film Thin Film AQUAMAT Children 8.5% 10.9% 0.0022 Africa (230/2712) (297/2713)
Rapid • First line: IV artesunate Admit? Diagnostic • Second line: IV quinine Tests • Then oral, eg 3 days riamet
Seaquamat group, Lancet 2005, Dondorp A, Lancet 2010, Sharma H, QJM 2015 10
Haemolysis post-artesunate Treatment of uncomplicated malaria
. Parasitaemia < 2% . 1-3 weeks after artesunate . Patient ambulant . 7-22% incidence . No complications . Haemolysis of previously infected rbc
. 4 week follow up recommended 1. Riamet 4 tabs at time 0, 8, 24, 36, 48, 60 hrs 2. Oral quinine 600mg 8 hourly, min. 9 doses plus doxycycline 100mg od for 7 days or clindamycin 450mg tds for 7 days 3. Malarone 4 tabs for 3 days
Jaureguiberry, Blood 2014, Rolling, JID 2014
2 Malaria deaths www.thehtd.org
14
Malaria deaths Same day film?
Purpose of Case fatality rate p value Travel (deaths/ cases)
Tourism 2.96 <0.001 (81/2740)
Visiting friends 0.32 <0.001 and relatives (26/8077) 15 16
Case 1 Is there anything we’re missing?? . 28 years old student . Temperature: 38.6ºC
. Pulse: 100 regular Malaria . 48 hour history ? . . Fever BP: 110/60 Virus URTI / influenza . aching muscles . RR: 20 breaths/min arbovirus: dengue, . mild headache hepatitis A / B /E . Sats: 97% room air . loose bowels Acute EBV, CMV
HIV seroconversion . Born in Nigeria . CVS, RS, GI, CNS: Bacteria enteric fever . One month trip home to unremarkable gastroenteritis visit family other bacterial sepsis . Returned 1 week ago typhus . No malaria prophylaxis Protozoa amoebic liver abscess ? 18
3 VHF early management Viral haemorrhagic fevers (VHF)
. Need to exclude malaria
. Careful with further investigations
. Isolation protocols
https://www.gov.uk/government/uploads/system/uploads/attachment_dat a/file/365845/VHF_Africa_960_640.png 19
Confirmed cases of MERS-CoV 2012-2015 MERS CoV
Severe acute respiratory illness • With fever and cough AND • Signs of consolidation or ARDS
AND • Travel to endemic area within 14 days • Contact with confirmed case within 14 days OR www.who.int
21 22
Case 2
. Arrived from Bangladesh 2 weeks ago Examination Investigations . 2 weeks fever, coryzal symptoms, dry cough, headache . Temperature: 40.8ºC . Fbc normal . Pulse: 133 . Na 133 mmol/L (135-145) . 2 days diarrhoea . BP: 130/84 . Bili 10 umol/L (0-20)
. RR: 20 breaths/min . Alk phos 118 IU/L (35-104) . Background . Sats: 97% room air . Alt 93 IU/L (10-35) . Alb 43 g/L (34-50) . Born in UK . CVS, RS, CNS: unremarkable . CRP 94.8 mg/L (0-5) . 3 week trip to Bangladesh,
returned 1 month ago . Malaria film –ve . No malaria prophylaxis . CXR: normal . Blood, urine, stool cultures pending moderately tender 24
4 Differential diagnosis “Classical Tropical Diseases” Malaria 805 Gnathostomiasis 4 Leishmaniasis 290 Brucellosis 4 Chronic fever Enteric fever 78 Hookworm 3 . Enteric fever (typhoid) You are called by Dengue 48 Post malarial neurological syndr. 2 microbiology Hansen’s 41 Dysentery 2 . Tuberculosis Hydatid 36 Madura foot 2 . HIV + opportunistic Loa loa 30 Cholera 1 infection Schistosomiasis 26 Tropical sprue 1 “gram negative rods on his Tick typhus 23 Anisakiasis 1 . Deep seated abscess blood culture” Amoebiasis 20 Ascariasis 1 Cysticercosis 18 Histoplasmosis 1 . Amoebic liver abscess Eosinophilia 14 Mansonella 1 Leptospirosis 9 . Brucellosis or Q fever Ciguatera poisoning 1 Strongyloides 9 Parasitophobia 1 Trypanosomiasis 7 Taenia 1 Wuchereria 6 Tropical pulmonary eosinophilia 1 . Non-infectious Onchocerciasis 5 Rabies 1 Chikungunya 4
http://www.ludekvincent.wz.cz/bacteriology_salmonelosis.htm
Typhoid Typhoid: antibiotic resistance
. Salmonella enterica . Non-specific symptoms: serotype typhi / paratyphi . Fever . Headache . Myalgia and lethargy . Through-out tropics, . Diarrhoea / constipation especially Asia . Dry cough
. Faecal-oral spread . Signs: Splenomegaly
. Investigations: . IP: 7-18 days (3-60 days) . ↓ platelets . transaminitis (mild)
www.who.int 28
Clinical progress:
. ~90% of cases travelled to Ciprofloxacin 750 mg BD Indian sub-continent IV/oral (2011) Enteric4 fever has 7a long fever 12
Day clearance time (regardless of Suspect bacterial infection in patient antibiotic choice)
returning from abroad?. If unstable: Ciprofloxacin < 4 days . Ceftriaxone (average) Think antibiotic resistance! Ceftrixone 7 days Azithromycin 5-7 days . If clinically stable: (particularly if patient has been in hospital.....) . Azithromycin No growth S. paratyphi A S. paratyphi . Ciprofloxacin doesn’t work! Ciprofloxacin sensitive A Patel AJTMH 2010; Hume et al Eur J Clin Micro Inf Dis 2009; Cooke F et al Trav Med IF 2004
5 CASE 3: 35 year old male Febrile 37.8°C Pulse 100 Holiday in South Africa BP 120/72 . 4 day safari in Kruger National Park . 3 days in Johannesburg at the football Sats 96% RA world cup
Day before return: . Fever Maculopapular rash ? . Headache Eschar . Myalgia . No localising symptoms
Presented to hospital directly from Heathrow
Which of the following is the MOST likely Tick typhus - Rickettsia diagnosis? . 18 species but majority travel associated cases: . R. africae: Sub-Saharan Africa, Carribean . R. Connorii: Mediterranean, Middle East, India, Africa A. Malaria . Majority spread by hard ticks B. HIV sero-conversion . Incubation period: 5-7 days (up to 10 days)
. Clinical syndrome: C. African tick typhus . Fever, headache, myalgia >80%
. Rash, eschar, regional lymphadenitis <50% D. Dengue . Treatment (empirical)
. doxycycline 3 days (confirmatory serology)
. Rapid clinical response
Case 4: SW Giardia
. Diagnosis: stool microscopy . 2 week trip to Peru multiplex PCR (HTD parasitology) . Returned with abrupt onset D&V, abdominal bloating duodenal biopsy . GP sent stool OCP
. Treatment tinidazole 2g stat . Treated with 14 days metronidazole OR metronidazole 500mg tds 7 days . Diarrhoea improved but bloating persisted
Refractory disease . HTD: Stool microscopy NEGATIVE Stool PCR POSITIVE for G intestinalis Increasing, especially in giardia infection from India
. Treated: tinidazole 2g stat Re-treatment
. No change in symptoms. Further OCP and PCR negative (X2). Repeat tinidazole 2g stat (55% efficacy)
. Trial of lactose-free diet, further review pending Tinidazole/ albendazole combination (60% efficacy) 35 (Mepacrine - poor tolerability) (~100% efficacy) 36
6 Travellers Diarrhoea Travellers Diarrhoea
st . 50% resolve within 48 hrs - so presents within country or within 1 week post-travel
. 50% no diagnosis made (E coli, viruses)
. Investigate in primary care??
. Antibiotics beneficial in shortening duration
. Ciprofloxacin 750mg stat or 500mg bd 3 days
. S Asia: Azithromycin 1g stat or 500mg 3 days
38 Steffen et al JAMA 2015
HTD data
Non-pathogenic parasites commonly reported . Stool pathogen detected in 13% patients attending walk-in with diarrhoea in stool samples
. The longer the history, the less likely a bacterial cause . Entamoeba histolytica/dispar
. Entamoeba coli
. 75% patients with bacterial cause had raised CRP . Entamoeba hartmani
. 55% patients with bacterial cause had a fever . Blastocystis hominis
. Formed stools just as likely to be positive . Balantidium coli
. = Dirty water !
Travellers diarrhoea: primary care Travellers diarrhoea- role for antibiotics?? investigations
. Stool MC&S, OCP . Prophylaxis?
. HIV . Who? Immunocompromised
. Fbc (eosinophilia) Patients at high risk from dehydration
. (Strongyloides serology) . What? Fluoroquinolones No good evidence for probiotics When to refer . Presumptive treatment? . Fever ……. refer for urgent malaria film . Who? Debatable- shortens duration to 1.5 days (consider viral haemorrhagic fever) but stewardship….. . Bloody diarrhoea . What? Loperamide (not if fever/ bloody diarrhoea) . Abdominal pain Ciprofloxacin 3 days . Ongoing diarrhoea Azithromycin stat (S and SE Asia- 41 campylobacter) 42
7 JW: investigations Case 5: JW . Hb 145 g/L . Alt 389 IU/L 9 . Wcc 2.89 x10 /L . Bili 7 umol/L . 32y male 9 . Returned from 3 week beach holiday in Thailand . Neut 1.44 x10 /L . Alp 55 IU/L 9 . 2 weeks rash, diarrhoea, fatigue, malaise, myalgia, . Plt 123 x10 /L . Alb 40 g/L anorexia
. Na 132 mmol/L . Hepatitis A: past infection . Maculopapular rash . K 4.4 mmol/L . Hepatitis B: immunisation . Urea 3.9 mmol/L . Hepatitis C negative
. Cr 76 umol/L . HIV ab negative
. But HIV Ag positive 6 . HIV viral load 11x10 43 copies/ml 44
JW: diagnosis London HIV prevalence
. Acute HIV infection
. Immediate appointment with health advisor at Mortimer Market downstairs
. Consideration of early ART
45 46
Summary
. Fever
. Malaria
. Typhoid
. Rickettsial infections
. Dengue/ chikungunya
. HIV
. Diarrhoea
. Travellers diarrhea usually bacterial
. Chronic diarrhoea usaually parasitic (giardia, cryptosporidium) [email protected]
. HIV, malaria
. Consider empirical treatment (elderly, co-morbidtiy)
. Rash
. HIV, others (Mike Brown) 47 48
8