david bell tropical fevers and rashes handout

Tropical Fevers and Rashes: 

Tropical Fevers and Rashes Dr David Bell Specialist Registrar Royal Liverpool University Hospital Liverpool School of Tropical Medicine November 2007

Asylum seekers: 

Asylum seekers 2/3rds from tropical Asia or Africa Dispersal throughout the country Infectious and parasitic diseases account for: 25% of the disease burden in low and middle income countries 3% in high income countries Migrants at ongoing risk of infectious diseases after arrival

Non-UK born account for:: 

72% of new TB cases in UK 70% new HIV cases 70% of malaria cases > 95% new chronic hepatitis B diagnoses 85% of migrants have health needs similar to matched UK born individuals Mental illness, drug misuse, poor nutrition, torture, abuse more common Non-UK born account for:

Slide4: 

TB HIV Hep B

Important questions: 

Important questions Country of origin Other countries visited in transit Time and conditions during transit: refugee camps etc Previous vaccination status if known Previous medical problems

Notifiable Infections: 

Notifiable Infections Everyone, irrespective of residence status, is entitled to NHS care for notifiable infectious diseases. Includes: Malaria TB Gastroenteritis Enteric fever Typhus Meningitis

Fever: 

Fever Huge list of potential causes Vast majority caused by standard infections; UTI, LRTI etc Malaria should always be considered. Falciparum rare > 3 months after leaving endemic area Vivax / ovale may persist for years.

Common sense approach to PUO: 

Common sense approach to PUO Establish the presence of fever before investigation Unexplained fever (if documented) requires investigation Retrospective investigation of fever that has settled is pointless

Incubation period < 21 days: 

Incubation period < 21 days Malaria Enteric fever Arbovirus, e.g. dengue, chikungunya Gastroenteritis Typhus (louse borne, flea borne, scrub) African Trypansomiasis Leptospirosis Viral haemorrhagic fevers

Incubation period > 21 days: 

Incubation period > 21 days Malaria TB Viral hepatitis HIV Schistosomiasis (Katayama fever) Amoebic liver abscess Leishmaniasis Filariasis

Fever and localizing signs: 

Fever and localizing signs Rash - dengue, typhoid, HIV, syphilis, typhus Jaundice - malaria, hepatitis, leptospirosis Lymphadenopathy - HIV, TB, typhus Hepatomegaly - malaria, hepatitis, leptospirosis, amoebic liver abscess, typhoid Splenomegaly - malaria, typhoid Eschar - typhus, CCHF, tick-borne encephalitis

PUO - Investigations: 

PUO - Investigations FBC, U&E’s, LFT’s Malaria – EDTA sample – repeat if suspicious Blood cultures Save serum for serology Urine analysis and culture (+/-OCP) Stool for MC&S and OCP Hot stool – Amoebiasis Fresh stool - Strongyloides CXR Check G6PD status before prescribing Primaquine

Tuberculosis: 

Tuberculosis 1/3rd world TB infected 5% - 10% will develop tuberculosis disease Risk greatest within the first five years Only Pulmonary TB is infectious esp. ‘smear positive’ Extra-pulmonary TB (LN, GI) more common in migrants than UK born, 48% vs. 27% Problems of multi-resistant TB organisms

Slide14: 

Tuberculosis notifications, England and Wales 1913 - 2006

Tuberculosis: 

Tuberculosis 72% of new cases of TB reported in 2005 were born abroad TB rate 25 times higher in the foreign born population than in people born in the UK 45% originated from South Asia and 39% from sub-Saharan Africa; Median 4 years to disease from entry into UK

Tuberculosis - clinical: 

Tuberculosis - clinical Suspect if chronic fever, cough, weight loss and unexplained symptoms Investigations: 3 x Early morning sputa CXR Other – FBC, LFT Referral to Infectious Diseases or Chest clinic

TB screening and BCG : 

TB screening and BCG Up to 50% of asylum seekers will be Mantoux positive BCG provides variable protection UK BCG policy Infants living in districts with TB incidence is > 40 per 100,000 Infants with parents or grandparents born in an endemic country New immigrants may also receive BCG after tuberculin skin testing (<16 vs. <30) Tuberculosis incidence rates, WHO global health atlas - http://globalatlas.who.int/globalatlas/

HIV: 

HIV 70% new HIV diagnoses are non-UK born, most were born in sub-Saharan Africa. In 2004, 2.2% of Antenatal women born in sub-Saharan Africa were HIV infected vs. 0.2% in UK born women Present at a late stage of infection, >90% diagnosed with AIDS within three months of their HIV diagnosis. ?How many know of status before arrival

Who to HIV test and how?: 

Who to HIV test and how? Unexplained symptoms / fever / weight loss Suggestive clinical features Consider background prevalence in country of origin All pregnant women screened at ANC Need verbal consent from patient to test If positive refer to Infectious Diseases clinic

Malaria: 

Malaria 2000 cases per year in UK 70% in those born outside the UK Falciparum rare more than 3 months after leaving endemic area Refer all falciparum cases to hospital (ID Unit) Non-falciparum malaria can be managed as OP Vivax / ovale may persist for years Most infections in asylum seekers are vivax / ovale Treat blood stage and liver stage parasites

Viral Hepatitis: 

Viral Hepatitis Hepatitis A or E rare, mainly from Indian subcontinent Chronic carriage of Hep B up to 20% UK Hep B carriage 0.3% 96% of new chronic hepatitis B infections in UK Hep C carriage - UK 0.5% vs. Africa 5%, Asia 2.5% ? Value of routine screening Abnormal LFT can reflect a vast number of different diseases Detection allows vaccination of susceptible family members (Hep B) Treatment available for Hep B and C in UK

Meningococcal disease : 

Meningococcal disease Most disease in the UK is caused by serogroup B Serogroup A is the main cause of disease in Africa and Asia Serogroup W135 associated with the Hajj pilgrimage outbreaks

Fever and Diarrhoea: 

Fever and Diarrhoea Shigella and Entamoeba histolytica Salmonella, Campylobacter and Cryptosporidium are common worldwide Enteric fevers (Typhoid and paratyphoid) Typhoid vaccine, 50-70% efficacy Management: Stool sample +/- empirical antibiotics e.g.ciprofloxacin Persistent diarrhoea is usually caused by protozoan parasites such as Cryptosporidium and Giardia

Slide24: 

To show NAR/resistance from Bhan et al Lancet 2005 Typhoid drug resistance

Eosinophilia causes: 

Eosinophilia causes Tropical : Helminth infections Non- tropical : Asthma, eczema, NSAIDS, drug hypersensitivity,CTD Up to 40% asylum seekers have intestinal parasites Screening? Poor negative predictive value Parasitic diagnosis is more likely with higher eosinophil counts, >1.0.

Common UK helminth diagnoses: 

Common UK helminth diagnoses HPA website

Helminth causes : 

Helminth causes Nematode (roundworms) A. lumbricoides Hookworms Strongyloides spp Trichuris trichiura Loa Loa Onchocerca volvulus W. bancrofti Toxocara spp Other species hookworms Clues Visible worms, Loeffler’s Anaemia; Loeffler’s Diarrhoea; rash; eosinos Bloody diarrhoea Eyeworm; calabar swelling Blindness; rash; nodules Elephantiasis Visceral larva migrans Cutaneous larva migrans

Helminth causes : 

Helminth causes Trematodes (flukes) Schistosoma spp Fasciola hepatica Clonorchis and Opisthorcis spp Paragonimus spp Clues Exposure history; Katayama fever; blood in semen, urine, stool Tender hepatomegaly Cholangitis-like illness Haemoptysis

Helminths: 

Helminths Cestodes (tapeworms) Hymenolepsis Nana Taenia Solium Taenia Saginatum Echinococcus spp Clues Vague abdo pain Uncooked pork, beef, cysticercosis Sheep, liver cysts

Management - Eosinophilia: 

Management - Eosinophilia Once detected, targeted investigation should be led by: careful travel & exposure history careful symptom history Include examination of stool, urine (and sputum) and appropriate serology Consider trials of therapy Albendazole for most roundworms (and filariae) Praziquantel for Schistosomiasis

Tropical skin disease: 

Tropical skin disease Fungal infections common in hot climates and with HIV Acute schistosomiasis Cutaneous larva migrans Larva currens - strongyloides Cutaneous leishmaniasis Myiasis Tungiasis Eschars HIV associated skin lesions

Myiasis: 

Myiasis The invasion of living tissue by the larva (maggots) of flies Tumbu fly - Africa Bot fly - South America Lay eggs on clothes: larvae invade skin to form boil like lesions

Mycetoma: 

Mycetoma Chronic subcutaneous infection caused by actinomycetes or fungi

Strongyloidiasis: 

Strongyloidiasis Larva currens rash

Web based diagnostic software: 

Web based diagnostic software Fever Travel www.fevertravel.ch Based on Swiss clinic algorithms GIDEON Web www.GIDEONonline.com Based on long established database of infections worldwide – subscription based

Advice sources: 

Advice sources National Travel Health Network and Centre (NaTHNaC) www.nathnac.org – up to date outbreak information Health Protection Agency www.hpa.org.uk Liverpool School of Tropical Medicine & ID unit RLUH On call 24hr x 365 via RLUH 0151 706 2000 ProMED – outbreak information http://www.promedmail.org