Fever In Returning Traveler

Fever In Returning Traveler

1. Blood and Tissue Protozoa

   • Plasmodium species
     • Plasmodium vivax
       • Liver stages
         • Persistent hypnozoites, relapse
       • Microscopical features
         • Enlarged RBCs
         • Rings are big and coarse
         • Trophozoites have ameboid appearance
         • Gametocytes are round, oval and covering the surface of RBC
         • Schuffner's dots in RBC
       • Predominant areas (World wide)
       • RBCs invaded
         • Young immature erythrocytes
     • Plasmodium ovale
       • Tertian malaria
       • Microscopical features
         • Oval, jagged, enlarged RBCs
         • Schuffner's dots
         • Trophozoites have compact and irregular appearance
         • Schizonts have rosette shape
         • Gametocytes are round in shape
       • Liver stages
         • Persistent hypnozoites, relapse
       • Predominant areas (Tropical Africa)
       • RBCs invaded
         • Young immature erythrocytes
     • Plasmodium malariae
       • Quartan malaria
       • Microscopical features
         • RBCs are not enlarged
         • Parasite has bar and band appearance
         • Rosette schizonts
         • Ziemann dots
         • Round to oval shaped gametocytes
       • Liver stages
         • No persistent stage, recrudescence
       • Predominant areas (Subtropical and Temperate areas)
       • RBCs invaded
         • Mature erythrocytes
       • Complications
         • Nephrotic syndrome
     • Plasmodium falciparum
       • Malignant tertian malaria
         • Irregular fever, most severe and fetal
       • Microscopical features
         • Normal sized RBC
         • The rings are fine, small and multiple
         • Crescent shaped gametocytes
         • Maurer’s dots
         • Peripheral smear
           • Early ring stage and gametocytes stages
       • Liver stages
         • No persistent stage, recrudescence
       • Predominant areas
         • Tropical Africa, Asia, Latin America
       • RBCs invaded
         • All erythrocytes
       • Complications
         • Due to
           • Invades all erythrocytes
           • High parasitaemia
           • Rosetting
           • Sequestration
           • Ligands
             • Plasmodium falciparum erythrocyte membrane protein
           • Receptors
             • Placental binding receptor (Chondroitin sulfate A)
             • Endothelial cells receptors (CD36, ICAM-1, E-selectin)
           • Cytokines
             • TNF-a , IL1, IL6, Nitric oxide
         • Cerebral malaria
         • Severe anemia
         • Severe hypoglycemia
         • Blackwater fever
         • Hepatosplenomegaly
         • Nephrotic syndrome
         • Poor pregnancy outcome
         • Liver or spleen failure
     • Causes
     • Life Cycle
   • Toxoplasma species
     • Toxoplasmosis
       • Caused by Toxoplasma gondii
         • Intracellular parasite
           • Natural reservoir (Cat)
             • Immunocompenet
               • Asymptomatic or lymphadenopathy
             • Immunosuppressed
               • Severe symptoms: swollen glands, fever, seizures, headache, psychosis, and problems with vision, speech and movement
       • Congenital toxoplasmosis
       • Diagnosed by Antibody detection
         • IgG / IgM / PCR
   • Trypanosomes species
     • African trypanosomiasis
       • Two subspecies
         • Trypanosoma brucei gambiense
           • Single central nucleus and a single flagellum
           • Undulating membrane / Covered by glycoprotein
         • Trypanosoma brucei rhodesiense
       • Symptoms
         • Bite reaction
         • Parasitemia
         • Winterbottom’s sign
         • CNS involvement (Sleeping sickness)
       • Transmitted (Female tsetse fly)
     • American trypanosmiasis
       • Caused by Trypanosoma cruzi
         • Transmitted (kissing (riduvid) bug)
         • Causes
           • Chagas' disease
             • Chacoma
           • Chronic stages
             • Cardiomegaly
             • Megaesophagus
             • Megacolon
   • Babesiosis
     • Caused by Babesia microti
       • Intracellular parasite
       • Transmitted by (tick)
         • Enters the RBCs
           • Under microscope (Maltase cross form)
     • Causes
       • Tick fever (hemolytic anemia, jaundice, fever and hepatomegaly
     • Diagnosed by
       • Peripheral blood smear

2. Malaria

   • Epidemiology
     • 219 million cases of malaria in 2017
     • African Region 2017
       • 92% of malaria cases
       • 93% of malaria deaths
     • 5 countries accounted half of all malaria cases worldwide (2017)
       • Nigeria (25%)
       • Democratic Republic of the Congo (11%)
       • Mozambique (5%)
       • India (4%)
       • Uganda (4%)
   • Risk factors
     • Area of malaria
     • Bite from infected mosquito
     • Age (Young and old)
     • Travelers
     • Immune system deficiency
     • Pregnancy
       • Newborns (Transmission from the mother)
     • Blood transfusion
     • Poverty
     • Lack of knowledge
     • No access to health care centers
     • Environmental factors
       • No protective clothing
       • Exposed sleeping accommodations
       • Lack of insect repellent
       • No precautions and prophylaxis
   • Clinical manifestation
     • Prodromal Symptoms
       • Non-specific flu-like symptoms (anorexia, muscle pain, headaches)
     • Clinical Infection
       • Febrile attacks (Malarial paroxysms)
         • Three successive stages
           • Sweating stage (2 to 4 hours)
             • Fever drops rapidly and the patient sweats
           • Hot stage (2 to 6 hours)
             • Fever (41°C), flushed, dry burning skin, throbbing headache, nausea and vomiting
           • Cold stage (15 to 60 minutes)
             • Intense cold and strong shivering
         • Periodic Febrile Response
           • Caused by
             • Rupture of mature schizonts in all types of malaria
               • P.malariae, fever happens every 72 hours
                 • Quartan malaria
               • P.falciparum, fever may occur every 48 hours, however it is usually irregular and shows no distinct periodicity
               • P.vivax and P.ovale malaria, schizonts mature every 48 hours
                 • Tertian malaria
       • Fever
       • Chills
       • Headache
       • Myalgia
       • Nausea, vomiting, diarrhea
       • Abdominal pain
       • Cough
       • Hepatomegaly
       • Splenomegaly
       • Anemia
   • Pathogenesis
   • Invistigations
     • Thick smear microscope (Gold standard)
       • Detects parasites
     • Rapid Ag test (Most popular screening test)
       • Detects parasite specific antigen
     • Rapid Ab test
       • Detects antibodies to malaria parasites
     • ELISA Ab test
       • Detects antibodies to malaria infection
     • Molecular method (Very sensitive and expensive)
       • Detects the malaria gene
   • Managment
     • Treated appropriately > Prognosis is excellent
       • Uncomplicated malaria > improvement within 48 hours after treatment
         • Fever free after 96 hours
       • P,falciparum > Untreated > Poor prognosis
     • Drugs
       • Chloroquine
         • P.vivax and P.ovale
         • Prophylaxis and treatment in areas without resistant P.falciparum
         • Adverse effects
           • GI distress / skin rash / headache / retinal dysfunction (high dose)
       • Quinine
         • Treatment of multidrug-resistant malaria
         • Adverse effects
           • Cinchonism / hemolysis in G6PD deficiency / Blackwater fever / hypoglycemia
       • Primaquine
         • Eradication of liver stages of P.vivax and P.ovale
         • Adverse effects
           • GI distress / methemoglobinemia / hemolysis in G6PD deficiency
       • Atovaquone-proguanil (Malarone)
         • Adverse effects
           • GI distress / headache / rash hemolysis / folate deficiency
       • Mefloquine
         • Prophylaxis and treatment of multidrug-resistant P.falciparum
         • Adverse effects
           • GI distress / rash / headache / cardiac conduction defects and neurologic symptoms (high dose)
       • Artemisinins
         • Standard of care for all chloroquine-resistant malaria
         • Adverse effects
           • GI distress / rare neutropenia / anemia / allergic reactions / QT prolongation
       • Pyrimethamine
         • Not used alone for P. falciparum
         • Adverse effects
           • Megaloblastic anemia
   • Prevention and Control
     • Prevent mosquito breeding
       • Drain potential breeding sites
       • Outdoor insecticide spraying
       • Chemical & biological larvicides
       • Male sterilisation of mosquitoes
     • Avoid mosquito bites
       • Site dwellings away from breeding sites
       • Protective clothing
       • Insect repellants (DEET based)
       • Use of insecticide treated bed net (ITN)
       • Residual indoor insecticide spraying
     • Early diagnosis
     • Intermittent preventive treatment (IPT) in pregnancy
     • Chemoprophylaxis in non-immune travellers

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