Thanks to everyone who contributed to the discussions about Ms Oryema, a 32 year old nurse who had recently returned from visiting family and friends in Uganda. After returning to the UK she developed diarrhoea, fever, abdominal pain, cough and headache.
You can see the highlights of the discussion on Twitter in the storify.
Fever in the returning traveller is a common scenario encountered by those working in acute settings – including general practice, A&E and acute medicine – so all junior doctors should know how to investigate.
This week’s question setter was Sarah Lawrence, Final Year Peer-assisted learning SSC student at UCL Medical School. Our expert was Dr Mike Brown, Senior Lecturer and Consultant Physician in Infectious Diseases, London School of Hygiene and Tropical Medicine and Hospital for Tropical Diseases, UCL.
Information available at the start of the week:
Ms Oryema, a 32-year-old nurse has recently returned from Uganda where she has spent one month visiting friends and family. Two weeks after returning to the UK, she has become unwell. For the last two days, she has had diarrhoea, fever and abdominal pain. She has also had a cough and headache for the last 24 hours. Her only significant medical history is chronic plaque psoriasis, for which she uses topical emollients and steroids. She has no known drug allergies. She is a non-smoker and drinks around one glass of wine per night. She was born in Uganda but moved to the UK when she was 11 years old and usually lives with her partner in London.
Her observations are:
- Temp 38.3, pulse rate 95bpm, BP 110/75mmHg, respiratory rate 14, Sats 98% on air, GCS 15
- A: airway clear
- B: tachypneoic, air entry bilaterally, no crepitations or wheeze
- C: appears pale and sweaty, heart sounds normal, no peripheral oedema
- D: alert, pupils equal and reactive, no focal neurology
- E: abdomen soft, no masses, mild diffuse tenderness, but no guarding or rebound, bowel sounds present
Question prompting discussion on Twitter: How would you approach investigating and managing Ms Oryema?
1. Fever in the returning traveller is a common scenario encountered in a primary care and general medical setting. It is important that junior doctors have the ability to take a good travel history, including questions on: a detailed itinerary; type of accommodation; exposure-specific activities such as freshwater contact, healthcare work, vermin and sexual history; vaccination and chemoprophylaxis adherence; illnesses whilst travelling.
2. Malaria is a common cause of fever in those returning from the tropics. It is potentially fatal and has a case fatality in the UK of around 1% overall. This varies with a number of factors including age and previous exposure to malaria.
3. A high risk group for malaria infection in the UK are those who have been visiting family and friends. Misinformation about protection from previous immunity (which is lost quickly once one leaves an endemic country) or other reasons for non-adherence should always be explored
- CDC guidance on reviewing someone who has returned from travelling abroad
- Journal of Infection: Fever in returned travellers presenting in the United Kingdom: recommendations for investigation and initial management (2009).
- VHF risk assessment flow chart from the Health Protection Agency
- BMJ: Investigation and treatment of imported malaria in non-endemic countries (2013)
- National Travel Health Network and Centre factsheet on malaria
- Cochrane Database Syst Rev: Rapid Diagnostic Tests for diagnosing uncomplicated P. falciparum malaria in endemic countries
- UK malaria treatment guidelines from Public Health England
- Algorithm for initial assessment and management of malaria in adults from British Infection Society and HPA
Dr Mike Brown, Senior Lecturer and Consultant Physician in Infectious Diseases, London School of Hygiene and Tropical Medicine and Hospital for Tropical Diseases, UCL says:
There is a wide differential diagnosis for fever in the returning traveller. Taking a detailed travel history will help to narrow this. Important infectious causes to exclude in the case of Ms Oryema include: malaria, typhoid, acute HIV, hepatitis A and hepatitis E, acute schistosomiasis, rickettsial diseases such as tick typhus, and dengue fever. This is based on her symptoms, her risk profile and the common infectious diseases that are present in Uganda. Viral haemorrhagic fevers (VHF) such as Lassa and Ebola also must be considered as the risk of healthcare-associated transmission is high. Your hospital will have a protocol for VHF assessment so make sure you are familiar with it. A useful example is provided by the Health Protection Agency (see resources above).
Investigations should be comprehensive but targeted based on the information gained from the travel history and nature of presentation (incubation period etc.). Blood films for malaria should be performed in all travellers from endemic regions presenting with fever, ideally whilst the patient waits. Malaria can present with many different symptoms so don’t be put off. In this case Ms Oryema had gastrointestinal symptoms, but malaria remained a very important differential to identify early. Other investigations include: FBC, U&E, LFTs, CRP, viral serology (HIV, Hep A / dengue), blood cultures, stool culture/OC&P
Blood cultures are particularly useful for diagnosing typhoid as serological methods are not reliable. A Blood film is important for diagnosing malaria because rapid diagnostic tests are not 100% sensitive, particularly for some species, and do not tell you the level of parasitaemia, which has important prognostic and treatment implications in falciparum malaria. Blood films therefore remain the gold standard in resource poor and rich settings. Remember to call the lab to warn them you are sending an urgent sample if it is out of hours.
Malaria remains a potentially fatal but completely preventable differential diagnosis in travellers returning from endemic regions. Although there was a decrease in the number of malaria diagnoses in the UK in 2012 (1378, down 18% from 2011), a greater proportion of these were with the more serious Plasmodium falciparum than previously. The majority of these cases occurred in people visiting friends and family (70% of cases where a reason for travel was given) and those who had not taken antimalarial prophylaxis (Public Health England, 2013).
Intravenous artesunate is now the treatment of choice for severe malaria, as studies have shown better outcomes than intravenous quinine (Cochrane summary). For uncomplicated malaria, a range of oral options are used, such as Riamet (artemether/lumefantrine), quinine or Malarone (atovaquone/proguanil).