Tropical Fevers and Rashes

1
Tropical Fevers and Rashes

• Dr David Bell
• Specialist Registrar
• Royal Liverpool University Hospital
• Liverpool School of Tropical Medicine
• November 2007

2
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

3
Non-UK born account for

• 72 of new TB cases in UK
• 70 new HIV cases
• 70 of malaria cases
• gt 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

4
Hep B
TB
HIV
5
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

6
Notifiable Infections

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

7
Fever

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

8
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

9
Incubation period lt 21 days

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

10
Incubation period gt 21 days

• Malaria
• TB
• Viral hepatitis
• HIV
• Schistosomiasis (Katayama fever)
• Amoebic liver abscess
• Leishmaniasis
• Filariasis

11
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

12
PUO - Investigations

• FBC, UEs, LFTs
• Malaria EDTA sample repeat if suspicious
• Blood cultures
• Save serum for serology
• Urine analysis and culture (/-OCP)
• Stool for MCS and OCP
• Hot stool Amoebiasis
• Fresh stool - Strongyloides
• CXR
• Check G6PD status before prescribing Primaquine

13
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

14
Tuberculosis notifications, England and
Wales 1913 - 2006
15
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

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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

17
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
  gt 40 per 100,000
• Infants with parents or grandparents born in an
  endemic country
• New immigrants may also receive BCG after
  tuberculin skin testing (lt16 vs. lt30)
• Tuberculosis incidence rates, WHO global health
  atlas - http//globalatlas.who.int/globalatlas/

18
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, gt90
  diagnosed with AIDS within three months of their
  HIV diagnosis.
• ?How many know of status before arrival

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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

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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

21
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

22
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

23
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

24
Typhoid drug resistance

• To show NAR/resistance from Bhan et al Lancet 2005

25
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, gt1.0.

26
Common UK helminth diagnoses
HPA website
27
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, Loefflers
• Anaemia Loefflers
• Diarrhoea rash eosinos
• Bloody diarrhoea
• Eyeworm calabar swelling
• Blindness rash nodules
• Elephantiasis
• Visceral larva migrans
• Cutaneous larva migrans

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Helminth causes

• Clues
• Exposure history Katayama fever blood in semen,
  urine, stool
• Tender hepatomegaly
• Cholangitis-like illness
• Haemoptysis

• Trematodes (flukes)
• Schistosoma spp
• Fasciola hepatica
• Clonorchis and Opisthorcis spp
• Paragonimus spp

29
Helminths

• Cestodes (tapeworms)
• Hymenolepsis Nana
• Taenia Solium
• Taenia Saginatum
• Echinococcus spp

• Clues
• Vague abdo pain
• Uncooked pork, beef, cysticercosis
• Sheep, liver cysts

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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

31
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

32
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

33
Mycetoma

• Chronic subcutaneous infection caused by
  actinomycetes or fungi

34
Strongyloidiasis
Larva currens rash
35
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

36
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