Fever in returning travelers can be a dilemma for US trained healthcare providers. In addition to the usual medical problems that we see here daily, there is a wide array of other problems that are rarely seen here. Some can be difficult to diagnose.
Knowing the correct questions to ask can be tough, as each area of the world has its own infectious disease threats and associated health problems. What foods the patient has eaten, what animals they have come into contact with and the health status of persons that they visited might all be important clues in figuring out the diagnosis.
Many travelers make it back home without even knowing that they are ill, and they may not even realize that their problems are related to a recent trip. Years ago, I started my watch timer on the final day of a safari, while standing on the Serengeti Plains. I was back home 28 hours later, well within the incubation period for most tropical diseases.
Malaria, typhoid and viral hepatitis are some of the more common illnesses experienced by travelers. Parasitic infections, HIV infection, bacteremia and insect-borne diseases are also on the list, as well as traumatic injuries. The CDC has a listing of the infectious disease threats for most areas of the world listed on its website at https://wwwnc.cdc.gov/travel (Click the “Destinations” link on the left side).
Persons who have unprotected sex are at risk for HIV and other sexually transmitted diseases, so it is always important to ask whether sex tourism was the point of the trip, especially in those returning from Southeast Asia or Africa. Casual encounters involving businessmen, businesswomen or ordinary tourists also fall into this category. One such patient had a severe facial rash that was unresponsive to the usual antibiotics. When he came to my office, he told me about his encounter with a prostitute a week earlier, during a business trip to Malysia. He had performed oral sex on her prior to their other activities, unwittingly infecting his face and eyes with the virus.
Travel Medicine Case:
A Chinese male in his 30s, with annual travel to SE China, came to the emergency room reporting one week of abdominal pain, fever, chills, diarrhea, vomiting and dizziness. He was hypotensive on arrival. He had multiple studies done in the emergency room to try and figure out a cause for his problems.
He was given IV fluids and antibiotics, and all symptoms quickly resolved.
A CT scan of his abdomen showed a large hepatic abscess. Drainage cultures of the abscess fluid grew Klebsiella pneumoniae organisms.
His blood cultures remained negative over subsequent days, and he was able to go home after a few days in the hospital. Some of his lab tests remained pending at the time of discharge, and will need to be followed up later.
During his China visits, he ate local food, drank local water, had no unprotected sex, and had no travel to rural areas or any animal contact.
An Entamoeba histolytica serology was sent to see if he had a history of exposure to that organism. It came back negative.
He will receive 4 – 8 weeks of oral antibiotics for Klebsiella treatment, with repeat abdominal imaging later.
Medicine is becoming more “retailized”, with more fragmented care for Americans. In this age of high-deductible insurance policies, Consumers (we aren’t looked at as patients any longer) are shopping around and finding low cost, convenient care at Urgent Care centers, free-standing Emergency Rooms and drug store clinics. Nurse-practitioners and physician assistants provide care in such settings.
Often, a patient’s own physicians do not receive copies of records from such visits. If the retail clinic NP’s or PA’s miss a diagnosis, there isn’t much of a trail to follow, and any X-rays, lab results and history information are not readily available for review in one place, even when the patient is referred to a primary care provider or specialist who might be able to help.
Many of my patients have ongoing health issues that seem refractory to therapy. Their continued suffering is sometimes the result of inexperienced health practitioners, fragmented records, overlooked results or a combination of these. The convenience and low cost of visiting a retail clinic rather than a doctor who is familiar with your problems might be fine for a routine cold or scraped elbow, but might not be the best choice for more chronic and severe problems. The retail clinics are also there for a reason. They boost the income for their parent companies by increasing same store sales, especially of high margin pharmaceuticals and over-the-counter medications.
It is very important (more important than ever!) for patients to keep copies of visit notes, lab test results, radiology and nuclear medicine test reports and medications. Often, the answer to their health problems is actually there, hidden in the disconnected mess of paperwork, and it can be ferreted out with some effort and persistence.
Establishing a correct diagnosis can save both money and time, as well as preventing progressive problems that might lead to more serious issues later.
Here are a few good ones that I’ve come across over the years for you:
THE FIVE C’s OF SQUAMOUS CELL CARCINOMA:
C alcium (elevated)
C ollapse (obstructed bronchus)
C entral location
C igarettes associated
HI PLATELETS for the causes of thrombocytosis
E pinephrine / Essential
Defect: Can’t get bilirubin into cells
Defect: Can’t conjugate bilirubin
Defect: Can’t dump conjugated bilirubin
PEPCLASE for the causes of aseptic meningitis (CSF showing cells but no organisms)
P artially treated bacterial meningitis
E arly bacterial meningitis
P arameningeal inflammation (sinus or brain abscess, subdural hematoma)
L ead intoxication (children)
A septic meningitis (viral)
E arly granulomatous meningitis (fungus, mycobacteria, sarcoidosis, Toxoplasmosis, parasites)
PANCREATITIS for the causes of pancreatitis
Congenital (biliary atresia)
Rx ( thiazides, steroids, chemotherapy)
Endocrine(hyperparathyroidism, DKA, Cushing’s)
Autoimmune ( collagen vascular)
Infections (coxsackie, mumps, ECHO viuses)
Stones/spider bite or scorpion sting
And the CRANIAL NERVES, of course:
Some Spinal Accessory
Please let me know if you have any good mnemonics of your own!
Memorizing facts is all well and good, but always remember to treat your patients well and with respect!
“He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.”
Coccidioides imitis is a soil fungus that requires alkaline soil to grow. It is found in arid regions from California to Texas and in areas of Central and South America. It causes “Valley Fever”, which can mimic the flu, but is not contagious from person to person.
Coccidioides infection begins when animals or people inhale its arthroconidia. These are the soil form of the organism, usually found in the top four inches of desert soil.
Tourists passing through the Southwestern US may inhale large numbers of infectious arthroconidia.
When they reach the lungs, they grow and form spherules, the next stage in the Coccidioides life cycle.
Our immune response to the fungal infection can result in fatigue, fever, cough, chest pain, headaches, rash, nightsweats, muscle pain, joint aches, weight loss and poor appetite.
These are the symptoms of Valley Fever.
Valley Fever spherules in our tissues soon become surrounded by layers of white blood cells. Since the white blood cells can’t kill the fungus, they try to wall it off.
Each granuloma is like an onion, with multiple layers of immune response cells surrounding its core of Coccidioides spherules.
Pathologists can use a microscope to see these granulomata and spherules in a tissue biopsy, allowing them to diagnose the fungal infection. Serology tests for Coccidioides are available, too, but may be unreliable in certain patients.
Doctors may have problems diagnosing Coccidioides infection, especially in areas where the fungus does not reside.
Even with a relatively strong immune system, tissue destruction and lung cavity formation can occur from Coccidioides infection.
Theis patient has a left lung cavity (hole eaten in lung tissue) from the fungal infection.
Radiologists can turn up the contrast on CT scan images to better see the extent of Coccidioides lung disease.
(Compare upper to lower image)
The fungal lung infection can affect the adjacent pleural membranes, pericardium and even the heart itself.
Bacteria from the mouth can find their way into a Cocci cavity, forming an abscess. This can cause high fevers, chest pain and malaise. Coccidioides infection can cause lung scarring, shrinking the involved lung. This patient’s diaphragm is pulled up into a “tent” or peak from scarring near the cavity.
Pus that breaks out of a lung cavity into the adjacent pleural space forms an empyema.
Empyemas require a thoracostomy tube for drainage.
If the empyema fluid is too thick to be removed by tube, surgical drainage is required for resolution.
Video Assisted Thoracoscopy or open thoracic surgery are used to remove the pleural “peel” (the “peel” forms from severe inflammation and pus remaining in the pleural space for weeks or months).
Someone with a weak immune system may die from disseminated infection (when Coccidioides spreads out of the lungs to involve the brain, bones, skin or other sites).
Patients with emphysema, diabetes, cancer chemotherapy, ongoing pregnancy or other immunosuppressive problems are more prone to severe disease with Coccidioides fungus.
Persons of Filipino, Polynesian and African ancestry can also suffer severe problems with the infection. Their immune systems are less effective in controlling the fungus.
Patients with disseminated disease are unable to contain the fungus. Involvement of brain, bones, abdominal viscera, muscles and soft tissues can be life-threatening. Most cases of disseminated Coccidioides are fatal without treatment.
Coccidioides fungus can activate the immune system, causing rashes of all sorts.
Joint pain, fatigue, red eyes, ulcers in the mouth and swelling of the lips and tongue can all be present with the rash.
Erythema multiforme is a flat or somewhat raised rash of doughnut or ring-shaped lesions that have a red or purple color. The rings may be clearly evident as in the photo above, or less obvious, as seen below.
The rash, joint aches, lip and tongue swelling, fatigue and red eyes usually resolve promptly on treatment for Coccidioides infection. These rashes and other symptoms occur from immune system activation by the fungus.
Erythema nodosum is a different sort of skin inflammation than erythema multiforme. It consists of large tender nodules beneath the skin. These usually occur on the front of the legs, but they can appear anywhere on the body in patients with Coccidoides infection. No Coccidioides fungus is found in these lesions; they are due to immune system stimulation by the infection.
Coccidioides therapy may include the different classes of anti-fungal drugs shown above.
Azoles are commonly used in patients able to take oral therapy (fluconazole, itraconazole, voriconazole, posaconazole).
Echinocandins are less easy to use outside of a hospital, since they are given intravenously.
Amphotericin B formulations are also intravenous, and are usually given to more seriously ill patients.
For more information about Valley Fever, visit
Valley Fever Center for Excellence website.
STERNAL WOUND INFECTION AND DEHISCIENCE
One of the miracles of modern surgery is the ability to perform open chest procedures to bypass clogged coronary arteries, repair traumatic injuries, remove tumors and clear the pleural space of infection. Such procedures usually go well, but like any operation, can take a turn for the worse.
Patients who suffer sternal wound infection and dehiscience after chest surgery may have painful recoveries, suffer severe complications or even die.
Usually, skin bacteria such as Staphylococci and Streptococci are involved in these infections, but other organisms such as fungi and mycobacteria can also cause problems.
If the bony edges of the split sternum become infected (osteomyelitis), they may come apart. Breathing and coughing put tension on the wires holding the sternal halves together, and they may pull out of the softened bone. This can allow the sternum to spring open, ripping the overlying skin and making a direct route into the patient’s chest cavity for bacteria and air. Patients with this complication must reach a hospital with an ICU quickly.
The picture below shows what sternal wound infection & dehiscience looks like.
This video shows sternal wound infection & dehiscience. You can see the respiratory motion of the two halves of the sternum, with the beating heart behind them. An abscess had formed in the chest wall, and the sternal bone was infected. The wires holding the sternum together pulled out of the softened bone, and were removed when the surgeon drained the abscess and cleaned everything up.
(If above not working, try link here: https://vimeo.com/186106835)
The spaces surrounding each lung are under negative pressure relative to our atmosphere, helping our lungs inflate on each breath. When the chest is opened, that vacuum-assist disappears, and the lungs collapse. Patients who have had chest surgery usually have a thoracostomy tube or two in place after their procedure, attached to a vacuum hose to help re-inflate the lungs. Once their wounds have healed a bit, allowing the chest to again maintain its seal, the tubes can be removed.
After sternal bone debridement (clean-up), rewiring and wound closure, the patient usually needs thoracostomy tubes and a prolonged course of intravenous antibiotics to try and penetrate the infected bone. The antibiotic course may run for 6 weeks or more, and the infection can recur again, even years after apparently successful therapy.
I have had a bottle of resublimed iodine crystals for years -> I use them for water purification as described in this 1975 Western Journal of Medicine item (see the two attached pages).
I take the small one ounce bottle with a few crystals in it in my pocket on trips – it can be used over and over again.
I use my bandana to filter out large particles when filling my 1 quart water bottle with contaminated water. I simply cover the bottle opening with the bandana and place the bottle in the river or under a running water source to fill it. Supersaturated iodine solution from the little bottle gets added to the water in the 1 quart bottle, with 40 minute wait until it is ready to drink.
I always loosen the cap on the one quart bottle and invert it after adding the iodine. The treated water gets into the threads of the cap that way, preventing illness from retained unpurified water retained there.
Larger amounts of water can be prepared / treated in the same manner as the 1 quart bottle. Just increase the number of milliliters of supersaturated iodine solution accordingly for however many quarts of water you have in your storage container. The forty minute wait period still applies, and the water stays clean so long as it remains in the closed container.
Many water purification systems purchased by campers or international travelers are bulky, expensive, prone to failure or require batteries. This method has no such disadvantages and is light / easy to carry. My bottle at home has a lifetime supply of crystals, too. Even though my bandana is not a 2 micrometer filter (usually required to stop all bacteria), iodine takes care of any bacteria passing through. Salmonella, Shigella, Campylobacter, Yersinia, Vibrios, protozoa, viruses and Cryptosporidia are all killed by the halogen.
Immigrants and infectious diseases are a major concern in many areas of the world. Here is a list of the most common diseases carried by immigrants.
Large numbers of people are on the move across the globe, and infectious diseases are moving with them. Which diseases are they? How can we stop them? What sort of screening should be in place for immigrants?
Here is a list of the most common infectious diseases associated with immigration:
Injected by Anopheles mosquitoes, these protozoa infect our liver and red blood cells, destroying them. Periodic fevers, chills and severe body aches result, along with anemia.
New rapid tests can diagnose the malaria quickly, so that individuals can be treated and avoid infecting mosquitoes in the new areas that they enter.
Typhoid fever results when Salmonella bacteria enter the bloodstream from the colon.
Salmonella bacteria reside in water that is been contaminated by feces from humans or animals, and in poorly cooked eggs and chickens. Human chronic carriers may shed huge numbers of the bacteria in their stool, contaminating rivers, wells or other water supplies when they defecate in them or touch food with unwashed hands.
One in 10 people with cholera will have severe disease characterized by profuse watery diarrhea, vomiting, and leg cramps. In these people, rapid loss of body fluids leads to dehydration and shock. Without treatment, death can occur within hours. As with Salmonella, water and hands contaminated by diarrhea can cause rapid spread of the disease.
Hepatitis A and E are present in the stool of individuals soon after they become infected. Large numbers of new cases can occur in places where people are unable to wash their hands and touch food eaten by others.
Hepatitis B and C are present in blood and semen of infected persons. These are spread by needle-sharing, sex and blood transfusions.
In places where violence has occurred, open wounds can be a source for transmission of Hepatitis C, which is 100 times more contagious than HIV. Virus in wound fluids can enter through a small break in a caregiver’s skin to infect them.
Transmission through sex by persons who do not even know that they are infected is common in many third world countries (and still occurs in more advanced countries). Unborn children can also be infected, and testing of all pregnant women is advised.
The tests for these organisms are very sensitive, and are important in diagnosing the infections early (before HIV causes severe immune system damage, and before syphilis enters the brain or causes harm to the fetus).
Treatment for both is now available, but may be expensive in the case of HIV.
Highly contagious if active, TB is frightening. Antibiotic resistant strains are now common in many parts of the world. Testing is not always reliable, and problems are already advanced if the person has an abnormal chest x-ray.
Isolation and TB therapy with several antibiotics at once are necessary for control.
Hopefully, countries receiving immigrants and the countries of their origin will be able to afford to treat ill individuals adequately. Medications for HIV and TB in particular can be very expensive and in short supply.
Tropical diseases like Leprosy, Sleeping Sickness (trypanosomiasis), Chagas disease, Filariasis, and Schistosomiasis are not easily transmitted to others, but may cause health problems later for international travelers who do not receive medical attention.
Immigrant/refugee screening tests:
Acute hepatitis panel
Sputum ×3 if chest x-ray abnormal
Over the and parasite exam on stool
Albendazole/ivermectin empiric therapy
Vision and hearing assessments for children
I often see interesting, beautiful and inspirational things decorating my patient’s rooms. Gifts from families and friends certainly help people to feel better about being stuck in a dreary and boring hospital environment. Having something nice to look at can help individuals deal with pain, loneliness and depression, too.
Furry stuffed animals, plastic flowers, books, greeting cards and balloons usually aren’t much of a problem from an Infectious Disease standpoint.
Rosary beads, fetishes and other religious items are likewise not an issue.
Living green plants and blooms are beautiful, but can be a threat to immunocompromised patients who have reduced immunity. Wet soil and potted plants can grow mold, and flower vases containing cloudy water can contain bacteria of many types.
Battery powered waterfalls can be contaminated with skin organisms when patients and visitors stick their fingers in the water to play in it, and Legionella as well as other water-loving bacteria can cause pneumonia when they are aerosolized by these devices. These are best avoided, even in relatively healthy patients.
Therapy dogs and other pets have skin organisms similar to those of humans and other mammals, but if they are petted by many patients, their fur can certainly become colonized by antibiotic-resistant bacteria.
At some hospitals, I have even seen such animals allowed to touch the patients’ bedding, which might be contaminated by patient sputum/stool or blood. Although no outbreaks have been reported from such a source, it is always a good idea to use Purell or wash hands thoroughly with soap and water after touching the animals.
When choosing edible gifts, it might be wise to check with the patient’s nurse or doctor to see what sort of diet they might be on. Low salt or diabetic diets might not include rich chocolate candies or fried pork skins!
Hopefully, these few tips will help you to find happy and healing items for your hospitalized friends and famly.
Happy, Healing and Safe Gifts (first three always, fourth only in some circumstances)
Shigella sonnei was the organism isolated from the patient’s blood. She recovered completely after 5 days of treatment with ciprofloxacin.
Shigella symptoms: fever, stomach cramps, nausea, severe diarrhea, dehydration, low white blood cell counts and death.
It takes only 10 – 200 Shigella organisms to infect someone.
Shigella infects colonic epithelial cells with loss of blood, water and salt from the damaged colon. Bloodstream invasion and death occur in severe cases.
Worldwide, 5 – 15% of all diarrhea cases can be linked to Shigella.
Most cases and deaths occur in children younger than 5 years.
Infected children can suffer seizures.
Shigella flexneri causes problems in developing countries with poor hygiene and limited clean drinking water
Shigella dysenteriae is known for large outbreaks of disease.
Shigella sonnei is most common in developed countries.
Shigella infections occur during summer and early fall in temperate regions and during rainy season in tropical areas.
High risk groups include children in day-care centers, homosexual men, individuals in custodial institutions, migrant workers and travelers to developing countries.
1) Foods washed with fecally contaminated water or handled with dirty hands
(tossed salads, chicken, and shellfish)
2) Drinking contaminated tap or swimming pool water
3) Anal sexual contact
4) Flies (pick up the Shigella by landing on feces)
INCUBATION / DURATION
1 – 7 days / Usually lasts for 4-7 days
Shigella is contagious in the victim’s stools for 4 weeks after infection.
Asymptomatic carriers can also spread the infection for several months.
Shigella bacteria can be cultured from stool or a rectal swab.
Shigella organisms (especially those from Southeast Asia) are often resistant to multiple antibiotics.
Healthy people usually require only rehydration.
No vaccine is available against Shigella.
Handwashing and the below food and water safety precautions are the best protection.
Eat only food that is fully cooked and served hot.
Wash fruit in clean water and then peel it yourself.
Food and beverages from street vendors are often not safe.
Boiled water drinks served steaming hot (tea and coffee) are safe.
Unopened, factory-sealed cans or bottles, carbonated beverages, commercially prepared fruit drinks, bottled water, alcoholic beverages, and pasteurized drinks are considered safe.
Water on the outside of cans and bottles may be contaminated. Wipe them dry before opening or drinking from them.
Ice may be made from contaminated water. Ask that your drinks have no ice.