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>Tutorials > Sick
traveller
Author Has Joshi
22/12/98
- how to manage a patient
who has been abroad and presents with fever or jaundice?
- how should the unwell
returning traveller be screened ?
- which investigations
should GPs perform or request ?
Travel itinerary
- helps to define the risk
- malaria- central &
south America, sub Saharan & central Africa, central & south east
Asia, ocean
- viral haemmorhagic fevers
e.g. lassa fever- west Africa-including Liberia , Nigeria and sierra
Leone; Ebola hf in Sudan, Zaire and Kenya
- marburg in Zimbabwe, Kenya
and south Africa.
- arthropod -borne infections
e.g. dengue -tropics and sub tropics both old and new world
- enteropathogens- all areas
with poor food hygiene, contaminated potable water supplies or inadequate
sanitation
- short stop overs including
refuel in malaria zone
Consider
- contact with animals
- drugs
- injections +operations
abroad
Clinical examination
o skin lesions
o throat abnormality
o respiratory signs
o CNS signs
o alimentary signs
o systemic signs fever, rash, jaundice, breathlessness
o hepato/splenomegaly
Investigations
FBC
- leucocytosis- bacterial
infections
- leucopenia- typhoid , viral
infections
- eosinophilia-
helmenthiasis, schistosomiasis
- thrombocytopaenia- malaria
and dengue
Blood film- malaria
LFTs
MSU
Throat swab
Sputum
CXR- pneumonia, legionnaire’s' and tuberculosis
Faeces
- for microscopy ova &
parasites,
- c&s possible causes of
traveller's diarrhoea
- viruses- rota virus,
enteric adenovirus, astro virus, Norwalk agent
- bacteria -E.coli,
Shigella, salmonella, Campylobacter, yersinia enteroclotica, v.cholerae,
clostridia, aeromonas
- protozoa- giardia lamblia,
e.histolytica, cryptosporidium parvum (life-threatening for
immunocompromised), cyclospora cayetanensis ( a new coccidian parasite
found in travellers from Asia)
Summary
- take a detailed travel
itinerary including information on stopovers
- make a full inquiry about
prophylaxis before, during and after travel
- fever in anyone returning
from abroad must be investigated and followed up
- a febrile visitor from a
malarious area has malaria until proven otherwise
- fever + organ dysfunction (
respiratory, CNS, gut, liver) represents a medical emergency and needs
urgent hospital review
Symptomatic inquiry
o fever
o fever with rigors
o headache
o lesions & bites
o bloody diarrhoea
o skin rashes
o urinary dysfunction
o jaundice
o respiratory symptoms
History
o preventive measures taken before, during and after the travel
o common immunisations - polio, tetanus, typhoid and hepatitis -a
o less common ones- yellow fever, hep-b, menningo coccus a and c, diphtheria
and tuberculosis
o infrequent ones - rabies, japanese b encephalitis, tick born
encephalitis and plague
o medications such as anti malarial
o behaviour modifications- use of insect repellents, mosquito net, water, skin
protection and condoms
Traveller returning home with diarrhoea
Who?
- who is the patient ?
- are they young or elderly;
- do they have any coexisting
medical condition eg. diabetes, immunocompromised,
inflammatory bowel disease
Where?
- where has the patient been?
When?
- when did the pt. return and
what was the duration of stay ?
How?
- how did the patient
travel?
- back packing?
- cruise ship ?
Eating
- local food?
- inflight meals ?
What?
- what did the pt. do on
holiday?
- a detailed itinerary
narrows the differential diagnosis.
What vaccinations?
What prophylactic agents?
Summary
o enterotoxigenic e.coli is the commonest cause of traveller's diarrhoea
o provide patients with written guidelines on prevention
o reserve prophylactic antibiotics for short, important visits to areas of
greatest risk
o frequent travellers should receive hepatitis -a vaccine
o remember, malaria can present with diarrhoea