5 key points on fever in international travellers (clinical problem)

• a travel history should be obtained from anyone with a febrile illness
• malaria should be excluded in anyone with a fever who has been in a malaria-endemic area recently
• then consider dengue & other arbovirus infections if there has been mosquito exposure
• do not forget the neglected bacterial tropical infections: enteric fever, leptospirosis, scrub typhus & melioidosis
• do not forget to ask about potential risk for sexually-transmitted infections & HIV/AIDS

5 key points on enteric fever (lecture notes)

• potentially fatal infection caused by bacteria in the Salmonella Typhi group
• diarrhoea is uncommon in its early stages
• a rare infection where personal & community hygiene is of a high standard
• diagnosis is best confirmed in early infection by blood culture
• resistance to commonly used antibiotics is common

Trop Med revision in a day? Who said it can’t be done.

Oxford Handbook of Tropical Medicine, 3rd edn

Here are some on-line resources to assist you:

1. Expedition medicine
2. Malaria
3. Fever in an international traveller
4. Arbovirus infections
5. Diarrhoeal disease
6. Enteric fever
7. Neglected bacterial diseases
8. Pneumonia
9. Snake bite
10. Envenomation
11. Leishmaniasis

Self assessment questions:

Clinical scenarios

Key information sources:

• WHO neglected tropical diseases
• CDC Yellow Book on travel health
• Oxford Handbook of Tropical Medicine
• Manson’s Tropical Diseases

The μGnome is home. A little chastened, to be sure. But home in time for Christmas, and more than a little relieved to have been snatched from the jaws of enteric fever. Now is not the time for finger-pointing or recrimination. That can wait a little, at least until a definitive aetiology has been determined, the micrognosis known and a primary source of infection implicated. When the account has been properly settled the μGnome is resigned to becoming the feature of his own problem-solving clinical case; the logical conclusion of making the most of every learning opportunity.

But now is a time for celebration and thanks. His, in particular, go to the physicians and nursing staff at the best hospital in Western Australia, who eased his progress through the emergency department and medical wards to a speedy discharge. It is difficult for any doctor to step out of their professional role to place themselves entirely in the hands of others.  How much more difficult was the μGnome’s task of admitting said gnome to his own hospital while responsible for the out-of-hours clinical advice on infection – a very personal version of the command, Physician health thyself! Of course, it is easy for a pathologist to excuse himself on the grounds that this instruction only applies to physicians, and clearly exempts pathologists. Nevertheless, the μGnome was mightily relieved to hand over to thinking physicians when his own mind was clouded by the effects of infection. The possible range of infective agents responsible for fever in a returned international traveller just back from East Timor was too much for his ailing brain.

 It can do little harm to see hospital medicine from the inside once in a while. As the μGnome came to his senses he was struck by the many small kindnesses staff of all grades showed him. Senior physicians explained their decisions with the patience of Job. An emergency physician conspired to obtain the best inoculated blood cultures yet seen in the ED. An ID physican pondered the options and weighed the best course of action.  And the nursing staff – what a team! Stripped of the responsibilities of the health bureacracy, the intellectual gymnastics of differential diagnosis and the struggle for incremental improvements in clinical management protocols, the μGnome lay back and let his colleagues get on with the job of  making him better. It didn’t take them long.

Monday should see a return to business as usual.

And all in time for Christmas.

Blastocystis hominis

Here, as promised, is the complete set of teaching units on enteric infection.

1. enteric fever

   Download (PDF, 251.74KB)

2. intestinal protozoa

   Download (PDF, 252.74KB)

3. intestinal helminths

   Download (PDF, 231.72KB)

4. traveller’s diarrhoea

   Download (PDF, 172.54KB)

Other useful sources of information including up to date epidemiology, parasite images and life cycles include:

• the World Health Organization
• the Centers for Disease Control and Prevention
• the CDC Yellow Book on travel health

See also MicroGnome posts on winter diarrhœa , enteric fever and traveller’s diarrhoea.

If you missed this week’s Tropical Medicine Breakfast, here are the notes. An illustrated version of the Clinical Parasitology unit will appear later when the enteric infection module is complete.

• Enteric fever
• Enteropathogenic protozoa

Enteric Fevers - Clinical features

‘ Synopsis of Tropical Medicine’ P Manson-Bahr, Cassell, 1946.

Incubation period: averages 14 days ; may be 7-21. Wide range of severity ; on the whole paratyphoids milder than typhoid. Onset : in paratyphoid often sudden with rigor, headache, anorexia, bone-joint pains and insomnia. Coated tongue, dry mouth, moist facies, general apathy. Epistaxis more common in typhoid than para. Diarrhœa from commencement or alternating with constipation. Pulse: dicrotic and relatively slow. Meteorism + in typhoid; less in para. Enlarged soft spleen on second or third day; absent in many paras, sometimes in para. A.  spleen is palpable during convalescence. “Rose spots” on tenth day between costal margin and umbilicus; pale-rose colour, round or lenticular. More profuse in para, especially para A. ; sometimes petechial and resemble typhus. Usually cough and bronchitis. Low muttering delirium and coma vigil ; not seen in paras. Intestinal hæmorrhage and perforation rare in para.

   Typhoid-paratyphoid group characterized by pyrexia of remittent type ending by lysis, low pulse-temperature ratio, toxæmia, splenomegaly and rose spots (sometimes absent). Pulse rate is 20-40 beats per minute slower than normal pulse-temperature ratio.

   Para C., common in S. America, may resemble enteric or be a septicæmia complicated by arthritis, abscesses, cholecystitis and fixation abscesses. Culture of para C. often in abscesses after quinine injections. Mild cases common.

Relapses.- Frequent in para A. ; less common in typhoid and para B.

You might want to think carefully before your next mouthful. The up-coming Tropical Medicine Breakfast begins our series on enteric infections, with a slot on enteric fever and a second unit on parasitic enteropathogens. All those with a strong stomach are welcome! [calendar of events]

100706 TMB flier

Recent MicroGnome features on travel-related diarrhoea and parasitic enteropathogens:

• clinical problem-solving
• post-infectious lactose intolerance
• abdominal pain in overseas resident