Fever, diarrhoea & international travel

Clinical Case of the Febrile Returned Traveller

Ms A, a 23 year old aid worker who has just returned after half a year overseas. She spent six months on aid work in the Amazon region and had a two week holiday in Mozambique on her way home. She took no travel health precautions before or during her travel.

She developed fever and profuse diarrhoea on her last day in Mozambique, and went straight from the airport to the Emergency Department.

On initial examination she was alert and oriented, but unwell and dehydrated with a pulse of 120 and a blood pressure of 90/60. She had diffuse abdominal tenderness and a mildly enlarged spleen. Her chest was clear.

Q1. What is your differential diagnosis?

  • infectious enterocolitis: ETEC, Salmonella, Campylobacter, Shigella.
  • malaria
  • dengue
  • typhoid
  • pelvic inflammatory disease
  • appendicitis

The initial investigations were:

  • Hb  100
  • WCC  8.6
  • Plts  25
  • Na  135
  • K  4.8
  • Ur  13.7
  • Cr 149
  • Stool microscopy – no parasites seen

These blood investigations produced this result.

Q2. What are these investigations ?

Thick film to detect malaria parasites (Plasmodium species), and thin film to identify which species

Q3. What is the result?

Plasmodium falciparum, high level parasitaemia

Q4. What other widely available investigation would give a rapid confirmatory result?

Rapid HRP-2 card test for Plasmodium falciparum

Q5. What treatment would you commence?

  1. basic resuscitation comes first
  2. then intravenous antimalarial agent, preferably artesunate

The patient had a very stormy course.

  • she was given 8L iv crystalloid in the first 24h, iv artesunate (SAS Category A, requiring informed consent), and exchange transfusion (6 units packed cells)
  • despite this, she deteriorated and went into multiple organ systems failure and DIC, requiring 29 days in intensive care
  • she was discharged from hospital, having lost 8/10 toes to necrosis

Additional resources

Comments

  1. fever & diarrhoea in an international traveller quiz at Micrgnome. Can you pick the disease http://bit.ly/afTsWq

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