Category Archives: travel

Think it’s just the flu? Think again.

You learn early in medicine that you will never diagnose a disease that you don’t consider. We all suffer from tunnel vision, and this can result in misdiagnosis and ultimately significant morbidity for patients. Currently most of us are aware of the importance of a good travel history because of the recent Ebola virus outbreak that put everyone on heightened awareness for at least one continent hopping virus.

This is important because clinicians often assume that the acute onset of fever, sore throat, myalgias, headaches, and cough all point towards a diagnosis of influenza or an influenza-like illness (ILI). In many places in the United States, this would result in a prescription for Tamiflu and a discharge home regardless of the results of a flu swab, as it was in the case reported in this article. I’ll not discuss the evidence behind oseltamivir, but the fact of the matter is that patients want it and physicians give it. Nonetheless, the majority of the time the clinician would probably be right (or at least not horribly wrong). Dengue Mar 2 2015

This is all well and good, except that this patient didn’t have influenza. She actually had dengue, which she had picked up on a trip to Haiti that ended 7 days prior to presentation, consistent with the normal incubation period of 3-14 days.

Why does this matter? Because while dengue fever may not be necessarily life threatening, if it progresses to dengue hemorrhagic fever or dengue shock syndrome it certainly carries a worse prognosis. Typically this occurs in those previously infected, so a asking if there has been a prior diagnosis of dengue is also important. Then how do you distinguish between the two?

Clinically, one sign that can point in the right direction is that dengue can cause a truncal rash, which is uncommon in flu. Another vaguely nonspecific clinical finding is a bimodal or “saddleback” fever that persists for 3 days, resolves, and peaks again in 1-2 days. Typically most symptoms resolve in a week, barring severe complications.

Also, apart from dengue titers, most labs are nonspecific in distinguishing dengue from influenza. Both can cause elevations in CPK, transaminases, and the acute phase reactants (ESR and CRP). Both can also cause leukopenia and thrombocytopenia. One finding that is relatively specific is markedly elevated serum ferritin, which can also be elevated for Legionnaire’s disease, another ILI.

In the end, treatment of dengue is no different from that of influenza, mainly supportive care. People infected with dengue are more likely to result in hospital admission, so appropriate suspicion and testing may prevent the “bounceback” patient who ends up getting admitted. Proper diagnosis of dengue is also necessary for epidemiologic purposes. And while your febrile returning traveler might not have dengue either, you still need to make sure their ILI isn’t leptospirosis, MERS-CoV, Legionnaire’s, measles, malaria, meningococcal disease, or typhoid. Thus, keep an open mind, as those hoofbeats might be horses, zebras, or unicorns.

During Influenza Season: All Influenza-Like Illnesses Are Not Due to Influenza: Dengue Mimicking Influenza
http://www.jem-journal.com/article/S0736-4679(14)01439-5/abstract

Additional light reading available at the WHO page on dengue.

Fever in the returning traveler

The patient who returns from vacation with a fever is often a diagnostic dilemma. Unfortunately, up to 1 in 5 travelers to the developing world will get one within a few weeks of their trip. So how do you come up with a logical, evidence based diagnostic workup for a fever of unknown origin?
Thankfully, these authors reviewed the literature and came up with an easy to follow algorithm to work up a patient. It includes:

  • Taking a detailed history
    • Dates of travel
    • Exposures (Food, water, sex, animals, sick people, INSECTS)
    • Prophylaxis, either pretravel or during
    • Illnesses during the trip, and medications
    • Exposures after travel, as not all fevers come from the travel itself
  • Performing a thorough physical exam
    • Abdomen for hepatosplenomegaly
    • Eyes for conjunctivitis
    • Lymph nodes
    • Skin for rose spots, maculopapular rashes, petechiae, or purpura
    • Neurologic for AMS
  • Specific initial lab tests
    • CBC with manual diff
    • Chemistries and LFTs
    • Pancultures: stool, urine, blood
    • Urinalysis
    • Thin and thick blood smears
  • Knowlege of geographic distribution of diseases
    • Dengue and malaria are widespread
    • Plasmodium vivax in the New World, P. falciparum in Africa, and non-P. falciparum in Asia
    • Rickettsia, schistosomiasis, and filariasis in Africa
    • Enteric fevers (typhoid and paratyphoid) are common in South Central Asia
  • Knowlege of incubation period for diseases

table

Sadly, most of the evidence is consensus level or worse, so expect a lot of atypical presentations and results. It does make sense to not just fly off the handle and start ordering West Nile titers on everyone, but instead having a straightforward process to do it. They show this with three case vignettes that are great for adapting into some of your own simulation cases.

One last comment I have is that this paper is open access. That way, everyone can learn that a tourniquet test for dengue involves pumping a blood pressure cuff up to halfway between the patients systolic and diastolic pressure. It’s positive if they’ve got more than 20 petechiae/inch [square inch? -JH].

Fever in Returning Travelers: A Case-Based Approach
http://www.aafp.org/afp/2013/1015/p524.html

Better food safety through technology

When travelling, much thought goes into what  to eat. Not only do you have to get your party to agree on something, you have to make sure it’s safe. While guidebooks and travel websites often give advice, they might not be detailed enough for your specific situation.

Then what to do? Maybe go get this “Can I Eat This” app thoughtfully created by the CDC. It was reviewed in Travel Medicine and Infectious Disease in August, and came away with a recommendation for all travellers, especially those with young children.

I agree that there is probably a group of people this app would help immensely. It is well received, with a current 4 star rating at iTunes, and 3.5 star rating at google play. The app is organized by simple questions with discrete answers, so you’re basically going down a flowchart. Unfortunately, you would probably get the same information from this infographic, also provided by the CDC. Most of the negative reviews point out the flaws, in that even though it asks you your country, it really doesn’t have country specific advice. It simply breaks down countries into “developed” and “developing”.

It definitely errs on the side of being overly safe rather than possibly making you sick. It even goes so far as to tell you that you probably should not to eat sushi in the US (or Japan!). It is comical that the picture of “uncooked meat” is a few sushi rolls, so maybe there is a hidden message there. There is also a fair amount of humor to be found in their answers that you can find while perusing the app.

So while I think the information is reasonable, and the message is right, I can’t imagine trying to use this on a trip. It’s still too clunky to pull out and use while ordering, even with the simple menus. I do think it is worth a look before travelling to a country simply to get an idea of how you should expect to eat and drink while there. Maybe it will encourage the traveller to look for a more in-depth listing of foods safe to eat.

“Can I Eat This” – Review of a CDC app
http://www.travelmedicinejournal.com/article/S1477-8939(14)00160-4/abstract

International traveling with medications?

It’s something that most don’t think about. Many readers of this blog are lucky enough to not have chronic medical problems, but not all are. Still, most of us regularly interact with an increasing number of patients with chronic conditions. And more and more of those patients are traveling internationally, potentially due to the treatments they are now able to receive. But what are the rules for people travelling with their medications and medical devices?

Ryanair.b737-800.aftertakeoff.arp.jpgFlattenedRoundPills.jpg

These authors set out to figure out how hard it is to find the requirements for travellers who may need to bring medications or medical devices with them. They determined 25 popular destination countries for Australian tourists, and then searched their embassy websites for 5 categories of information pertaining to medications, required documentation, and customs information. They also sent an email to each embassy requesting information about the same topics. They then rated the embassy websites using the RATER scale, which is a modified Service Quality tool (SERVQUAL).

In 2 weeks, they got responses back from 11 of the 25 embassies they had emailed. This lack of service was mirrored by the impressively low scores the embassy websites received on their RATER scales. And even though the title and attempt of the study was to include medical equipment, neither the email responses nor the websites gave any guidance on medical equipment.

More concerning is the fact that no country followed the recommendations of the International Narcotics Control Board, which is an independent body that exists to help carry out the UN Drug Control Conventions.  All of them had more restrictive policies, some so severe as to require the patient to go to a local physician to certify that the medication is needed. Now, we mostly talking about narcotic and psychotropic medications, and generally supplies of less than 30 days. Anabolic steroids will also raise eyebrows in many countries.

Basically, the recommendations boil down to these.

  • Only possess your own medications
  • Carry the prescription or other documentation for those medications
  • Check with competent authorities in your destination countries well before travelling

For travelers planning on spending more than 30 days? Not much guidance, as you probably will have difficulty bringing it through customs initially, and you may have trouble getting prescriptions filled once there. And for those with medical devices (think neurostimulators), make sure to carry backup batteries and plenty of documentation for them.

Unfortunately, while the thought behind their study was valiant, the poor response rate combined with apparently terrible embassy websites means that each person travelling with controlled medications has their homework cut out for them. Still, without much else out there, it gives everyone a place to start.

Note that this doesn’t apply to medical providers carrying medications for expedition or humanitarian purposes. There is an entirely different set of rules for that.

Travelling with medications and medical equipment across international borders
http://www.travelmedicinejournal.com/article/S1477-8939(14)00133-1/abstract