The Febrile Returned

Traveler and Dengue Fever

AM Report
Sept. 25, 2009
 The Traveler
• Health problems are common in the
traveler
– Self-reported rate of 22-64% of people who
travel to developing countries
• The major categories are:
– Systemic febrile illness w/o localizing findings
– Diarrhea
– Dermatologic disorders
– Non-diarrheal GI disorders
 GeoSentinal
• Surveillance effort made up of the CDC
and International Society of Travel
Medicine
• Stretches out over six continents and
collects data on ill travelers
• Large study of almost 25,000 ill travelers
between 1997-2006 (all-comers)
– Non-specific fever was the chief complaint in
28%
 Febrile Illness
• For returned travelers presenting with an acute
fever Malaria was the #1 cause, Dengue Fever
#2
– 21%, 6% respectively, although it is thought that
Dengue is widely underrecognized and
underdiagnosed secondary to lack of knowledge on
the part of health care providers
– In travelers to SouthEast Asia, Dengue is the #1
cause of febrile illness
– In the Caribbean and South/Central America, they are
roughly even
• Numbers 3-5 are mononucleosis (EBV or CMV),
Rickettsial infection, and typhoid/paratyphoid
fever
 Dengue Fever – What is it?
• Mosquito-born virus
– Four, actually. DENV-1 through DENV-4
– Flavivirus genus
– Single strand RNA viruses
– Exposure to one serotype provides almost no
cross-protection to re-infection from other 3
types
• 50 million infections occur yearly
throughout the world
 Symptoms
• Typically start 4-7 days after the bite
– Incubation period of 3-14 days
• Spectrum, from asx infection to self-limited
fever to hemorrhagic fever
• Age is a big predictor for response –
children under the age of 15 tend to have
more asx infections (>50%)
 Classic Presentation
“Break-Bone Fever”
• Acute febrile illness
– Typically lasts 5-7 days
– Once fever disappears, prolonged fatigue (days to week)
is common
• Muscle/joint pain
• Headache/retroorbital pain
• Varied rashes common in primary infection
– Macular of maculopapular
• GI sx common in secondary infection
• Rarely (<10%), can have hematologic sx
– Purpura, spontaneous bleed, melena, metorrhagia,
epistaxis
 Lab Findings
• Thrombocytopenia (<100K)
• Leukopenia
• Elevated AST (2-5x upper limit of nl)
 More serious presentation –
Dengue Hemorrhagic Fever
• Four cardinal features, per the WHO
– “Plasma Leakage Syndrome”
• Increased vascular permeability defined by either
hemoconcentration (>20% rise above baseline crit),
presence of pleural effusion or ascites
– Thrombocytopenia (<100K)
– Fever lasting 2-7 days
– Spontaneous bleeding or a “hemorrhagic tendency” (ie
positive tourniquet test)
• Inflate BP cuff on arm to midway between systolic and
diastolic pressure, wait five minutes
• If >20 petechiae/sq inch on skin below the cuff, test is
positive
** If all four of these signs/sx plus shock  Dengue Shock Syndrome (DSS)
 Epi

• Dengue was the cause of about 10.4% of

post-travel systemic febrile illnesses
among travelers returning from Southeast
Asia
– Second only to malaria
• Most frequently identified cause of
systemic febrile illness among travelers
returning from Southeast Asia (32%),
Caribbean (24%), South Central Asia
(14%), South America (14%). Second to
malaria in Central America (12%)
 Diagnosis
• Other than specific WHO criteria for Dengue
Hemorrhagic Fever, classic DF has no clear
criteria
• Mostly clinical, based on signs/sx
• Epidemiological studies define it differently -
has been a problem for research efforts
• Hemagglutination Inhibition Assay is the gold
standard
• In developed countries, can do PCR, Ag
testing, or IgM/IgG immunoassay
 Prevention
• Tx is pretty much all supportive, so focus on
prevention
– Particularly those traveling to Asia, Central and South
America, and the Caribbean
• Tetravalent vaccines in development (animal
testing phase)
Mosquito Control (Aedes Aegypti)
– Insecticides not very
effective, as they breed
inside houses
– Community education to
reduce breeding site (tires,
other containers with
standing water)
– Standard methods to
prevent mosquito bites
(long sleeves, DEET, etc)
– Place a water bug,
Mesocyclops, in containers
 References
• Freedman, DO, Weld, LH, Kozarsky, PE, et al. Spectrum of disease
and relation to place of exposure among ill returned travelers. N
Engl J Med 2006; 354:119.
• Up-To-Date. Clinical presentation and diagnosis of dengue virus
infections. Updated January, 2009
• Steffen, R, deBernardis, C, Banos, A. Travel epidemiology--a global
perspective. Int J Antimicrob Agents 2003; 21:89.
• World Health Organization Public Website – “Dengue and Dengue
Haemorrhagic Fever”
http://www.who.int/mediacentre/factsheets/fs117/en/
• Wilson, ME, Weld, LH, Boggild, A, et al. Fever in returned travelers:
Results from the GeoSentinel Surveillance Network. Clin Infect Dis
2007; 44:1560.