#IDgrandrounds
30M +fever, ab pain, cough x 1wk. Back from Tanzania (swam in Lake Victoria) 2 mos ago. +vaccination/malaria prophy before trip. Blood smears (-). Eosinophil count 4,000.
Diagnosis/differentials? @Cortes_Penfield @TxID_Edu @BradCutrellMD @DocWoc71 @Darcy_ID_doc
@Cortes_Penfield @TxID_Edu @BradCutrellMD @DocWoc71 @Darcy_ID_doc 1/10
Thank you for all your responses! @TxID_Edu @BradCutrellMD @DocWoc71 @GermHunterMD @marschall_jonas @jdcooperid others
Stool sample demonstrated Schistosoma mansoni eggs.
CASE RESOLUTION: Acute schistosomiasis (Katayama fever)
mcdinternational.org/trainings/mala…
2/10
Katayama fever was previously covered here last year. Click below to review:
What I'd like to talk about briefly is my "𝔸𝔹ℂ𝔻𝔼" approach to generating an illness script for a febrile returned traveler.
3/10
𝔸: "Adventure"
▪️ Where did patient travel?
Common DDX: "🅼🅳🆁🆃" Malaria, Dengue, Rickettsial, Typhoid fever
▪️ Malaria in all regions
▪️ Dengue less in Africa
▪️ Rickettsial illness more in Africa
▪️ Typhoid more in Asia
Good review here:
nejm.org/doi/full/10.10…
4/10
𝔹: "Body"
▪️ What syndrome does patient have?
Common syndromes (fever +) & examples:
▪️ Respiratory: flu, TB, fungal
▪️ GI: bacterial, helminthic, typhoid
▪️ Fever w/o localizing: malaria, dengue, rickettsial, typhoid
Always R/O malaria even w/ or w/o localizing signs.
5/10
ℂ: "Chronology"
▪️ When do the SSX start in relation to date of return?
Some infections have short incubation periods, hence, expected to manifest soon after return. See Table below:
6/10
𝔻: "Defense"
▪️ What pre-travel vaccinations/prophylaxis did patient receive?
Gives the clinician an understanding of patient's over-all risk for certain preventable travel-associated infections.
7/10
𝔼: 1st E "Exposure"
▪️ The crux of the ID history!
✔️ "Street" food consumption?
✔️ Unpasteurized milk?
✔️ African game reserve?
✔️ Flood, triathlon?
✔️ Hajj pilgrim? etc
Beware of "buzzwords" though as it may anchor you to a diagnosis and bias the rest of your approach
8/10
𝔼: 2nd E "Eosinophilia"
▪️ Helps generate DDX!
𝙷𝚎𝚕𝚖𝚒𝚗𝚝𝚑𝚒𝚌 𝚒𝚗𝚏𝚎𝚌𝚝𝚒𝚘𝚗: most important DX to consider
Protozoas not a/w eosinophilia except Dientameoba & Cystoisospora.
Will refer you to @DocWoc71 response for more info:
9/10
Using this approach, Katayama fever has this illness script:
𝔸 Vast majority come from Africa
𝔹 Rash ➕ respiratory/GI usually (pic)
ℂ Occurs late; 3-8 wks
𝔼 53.7% of eosinophilia from returned travel; exposure to infected water
Taken from: ncbi.nlm.nih.gov/pubmed/18458300
10/10
Other things to know about Katayama:
1⃣ Happens in non-immune (travelers), rare in locals
2⃣ Rx is 𝗽𝗿𝗮𝘇𝗶𝗾𝘂𝗮𝗻𝘁𝗲𝗹 but is NOT larvicidal! Reason why a 2nd dose recommended 4-6 wks later.
3⃣ Steroids may be given w/ praziquantel (⬇️ inflammatroy response w/ Tx)
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