12 - Post-Travel Consultation, Diagnosis & Treatment

POST-TRAVEL CONSULTATION,
DIAGNOSIS & TREATMENT

dr. dewa ayu putri sri masyeni, sppd-kpti
Outline
• Overview of post-travel consultation
• Fever in returning travelers
• Eosinophilia
• Others
The Continuum of Travel Medicine
Preventive Medicine
Pre-Travel
Pre-Travel Visitors
Visitors
Contingency During
DuringTravel
Travel PLanning
Treatment & Post-Travel

Post-Travel
Rehabilitation
(Peter A Leggart)
Introduction
• The usuall presentation of returned travelers may
present with :
– Fever
– Respiratory infection
– Diarrhea
– Eosinophilia
– Skin, soft tissue infection
– Asymptomatic
• Epidemiology : almost 50% of the returning
travelers, and only 8% seek doctor
Post-travel consultation
• History
• Examination
• Investigations
Post-travel consultation
• Many travel related problem are self limiting
• Obtain complete :
– Travel history
– When, duration
– Potential exposure of exotic disease
– Time of symptoms onset in relation to travel,
may help eliminate diseases with different
incubation periode
Post-Travel Consultation
• It is important to elicit a history of travel.
• Many short term travelers will present with
illness when they get back, following the
incubation period.
• Investigation and management of some post-
travel illnesses will be urgent because they are
life threatening and/or a threat to public
health.
Follow-up of travelers
Do you see travellers
• Symptomatic on return?
• Symptomatic whilst aboard?
• Asymptomatic abroad and asymptomatic
now?
• To complete immunization courses?
Screening history
• Are they symptomatic now or have been?
• Risk assessment - leading to specific history of possible exposures,
e.g. schistosomiasis, zoonotic disease, sexual history, recently been
diving, have they been bitten?
• Is there correspondence in relation to treatment abroad?
• Travel history can be important in terms of working out possible
incubation period and differential diagnosis
• Prophylaxis and compliance - was the prophylaxis appropriate?
• Could it be a pre-existing condition?
• Could it be related to an occupational/recreational exposure

Screening examination
• Post-travel physical examination for most
short term travelers is usually unremarkable
for disease, but may be useful for assessment
of injuries
• Signs of “tropical” disease can be subtle and
can be missed unless specifically looked for,
e.g. rashes, eschar, jaundice
• Abnormalities unrelated to travel
Look for the “spot” diagnosis
• Hookworms and cutaneous
larva migrans: tracking
lesions on the foot (or
other body areas in contact
with sand/soil)
Look for the “spot”diagnosis
• Leishmaniasis: non-healing skin
ulcers/lesions, especially on exposed areas
and been to endemic areas
• Eschars-may be associated with rickettsial
infectious such as scrub typhus
• Skin infection: bacterial and fungal
(ask for occupational and recreational history)
• Others
Screening Examination
• When sending specimens to lab, document current
medications, history, what you think
• Liaise with lab if unsure what tests available
• Stool microscopy : most diarrhoeal disease
bacterial>>parasitic>viral
• Urine tests-dipstick urinalysis, “terminal” urine for
ova of S. haematobium
• Full Blood Count and differential- eosinophilia,
anaemia, thrombocytopenia
Screening Examination
• Rapid tests, e.g. Immunochromographic tests
(ICT)-often used for initial screening for malaria,
Bancroftian filariasis, (dengue), etc
• Serological investigations, e.g. schistosomiasis,
filariasis
• Blood films for malaria
• HIV/STI serology
• TB screening-useful if you can compare with pre-
travel
Travelers’ diarrhea
• Persistent diarrhea may be giardiasis, which

may need treatment with tinidazole or
metronidazole
• Chronic diarrhea may need further
investigation and referral
Has the traveler been injured abroad?
• Need to document extent of injuries
• Are they covered by any insurance or
superannuation policy?
• Arrange for any further treatment and follow-
up
• Liaise with airlines if further travel required
• Arrange for assessment for rehabilitation as
necessary
Fever in returning travelers
• Fever account 35% in returning travelers
• The travelers may have a life threatening infection
due to:
– Malaria ( P falciparum)
– Typhoid
– Amoebic liver abcesses
– Meiloidosis
– Legionaire’s disease
– Rabies
• Diagnosis of fever without local symptom may be
difficult
( Gherardine and Sisson, 2012)
• Dengue (2-5 days)
• Lassa, Ebola and others (3-21 days)
• Japanese Encephalitis (3-7 days)
• Yellow fever (3-6 days)
• Typhoid (10-14 days)
• Malaria (Pv-10 days to year-relapses; Pf 10-28 days)
• SARS (2-10 days)
Laboratory tets
• Complete blood count with diff. Count

• LFT
• RFT
• RDT malaria + malaria smear
• Urinalysis
• Blood culture
• CXR
Srub typhus/bush typhus
• Causa: intracellulare parasite : Orientia tsutsugamushi,
fam. Rickettsiaceae, first isolation in Japan Russia,
Northern Australia
• Vector : mites biteleave ‘black eschar’
• Sign&symptoms: fever, headache,myalgia, cough, GI
symptoms, hemorrhage, intravasc. Coagulation,
splenomegaly,
leucopenia
• Therapy: Doxycyclin/Tetra, Chloramph,
Rifampicin, Azythromycine
( Gherardine and Sisson, 2012)
• Management : specific therapy are
determined by the etilogy of each case
Leishmaniasis
• Parasite: Leishmania,
vector sandflies
• Asia, Africa, South/Central
America
• Affect: cutan, mucocutan,
visceral
• Prevention: bednet, DEET
• Th/ lisosomal amphotericin
B (visceral), paramomicyn,
fluconazol,pentamidine
(cutaneus)
EOSINOPHILIA
• Definition: absolut eosinophil count :> 0.44 x
10⁹/L of blood or ratio eosinophil > 10% from
total WBC count
• Allergies and Helminth (round worm or
trematoda) infection are the most common
causes
• Protozoa is not produced eosinophilia, except
Isospora belli
Eosinophilic syndromes
• Tropical (TE) & Loffler’s syndrome (LS) are two associated with
nematodes that have a larval phase involving the lungs of the
human
• Distinguishing features
Feature TE LS
Common associated Lymphatic filariasis Pulmonary phase os
infections ascariasis, hookworm ds,
strongiloides
Eosinophilia High, > 3000/µL Moderate 1000-3000
WBC Often high Normal
IgE level High,>10 000ng/mL moderate
Filaria serology High titre in absence of Negatif
microfilaremia
Response to Positive Negative
Diethylcarbamazepine
Physical, Laboratories Examination, Treatment
• Signs of anemia, abdominal/muscular
tenderness, hepato/splenomegaly,
lymphadenomegaly, defisit neurologies
• Lab : CBC with diff. Count, serum iron,
• Stool test: ova of worm
• Urine : Schistosoma ova
• Sputum: ova of Paragonimus or eosinophil
• CSF: eosinophil
• Tissues biopsy, Serology, Radiology
• Therapy: anthelmintics
TERIMAKASIH
Near drowning
• Definition : a process resulting in respiratory impairment
from submersion in a liquid medium
• ND refers to survival (even if temporary) beyond 24
hours after submersion (world congress,2002)
• Work up laboratories : Blood Gas analysis, CBC, d-Dimer,
Faal hemostasis, LFT, RFT
• Imaging study: CXR, CT scan
• Management: CPR, respiratory/cardiac support, brain
support, intensive care unit
Antibiotic (aspiration of bacterial, chemical),
Drowning

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POST-TRAVEL CONSULTATION,

DIAGNOSIS & TREATMENT

Treatment & Post-Travel

• Could it be a pre-existing condition?

• Could it be related to an occupational/recreational exposure

• Persistent diarrhea may be giardiasis, which

• Complete blood count with diff. Count

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