Page 982 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 77: Management of the Critically Ill Traveler 713

DIAGNOSTIC APPROACHES AND EARLY THERAPEUTICS Area of Origin Endemic Organism/Syndrome
■ EPIDEMIOLOGY AND TRAVEL HISTORY Central Asia Acute diarrhea

The rate of critical illness among the sick traveler is largely unknown, Dengue
but most likely occurs in a minority of cases. Given the wide array of Malaria
clinical possibilities, and the time-sensitive nature required in critically Influenza
ill patients with recent travel, epidemiologic clues provide the initial
pathway of treatment. When giving consideration to the more uncom- South and Central America and Caribbean Acute diarrhea
mon diseases, however, it is of paramount importance that investigation Dengue
and therapeutic intervention are also directed toward less exotic com-
munity acquired pathogens. 1,4,6,7,13 These epidemiologic steps are the Malaria (falciparum)
first clues to potential disease, with physical examination findings and Influenza
laboratory/radiology studies providing additional support for the diag- Histoplasmosis
nosis or path of empiric treatment. In essence, both rare and common
illnesses should be considered in a critically ill traveler. Coccidioidomycosis
A detailed travel history is essential for the identification of the patho- Yersinia, schistosomiasis
gen that has led to critical illness. 1,4,6,7,13 Table 77-2 outlines the major Anthrax
diseases of travelers by region. Careful attention must be paid to all
destinations, the seasons of visitation, and the extent of pretravel vacci- Plague
nation and prophylaxis. Expatriates and visitors are more likely to forego Endemic typhus
prophylactic measures appropriate for their sites of travel. Recently, Worldwide distribution Pneumococcus
data from 30 travel and tropical medicine sites on six continents have
been integrated to enhance our understanding of common pathogens Influenza
encountered by travelers. Based on these data, a few important gener- Leptospirosis
1
alizations can be made. First, malaria is among the top three pathogens Hepatitis A/E
causing severe illnesses in virtually all developing areas of the world, and
Rabies
Legionella
TABLE 77-2 Diseases Causing Critical Illness in the Traveler by Geographic Distribution
Area of Origin Endemic Organism/Syndrome
Sub-Saharan Africa Malaria (falciparum) is the most common infection in all sub-Saharan Africa. 1,4,6,7,13 Second,
dengue is an extremely common cause of illness from all developing
Acute diarrhea
areas outside of sub-Saharan Africa, followed by rickettsial diseases.
Dengue The length of time between visitation to each destination and
Influenza symptom onset can also provide useful insight as to etiology of severe
illness. Table 77-3 outlines the average incubation period of these
Schistosomiasis (mansoni, haematobium) major illnesses. Most entities have symptom onset within 7 to 10 days
Meningococcal meningitis of exposure, though some diseases like Plasmodia falciparum and acute
schistosomiasis may have a delay in onset between 1 and 2 months. 1,7,8,11,15
Trypanosomiasis
Pointed inquiry concerning the nature of environments encountered
Chikungunya (urban, rural, cruise, adventure travel) as well as direct exposure history
Viral hemorrhagic fever (Ebola/Marburg, (animals, fleas, sick contacts, untreated water) is also very important in
Rift Valley fever) diagnosis (Table 77-4). 1,7,8,11,15 Additional behaviors, from contact with
wildlife and domesticated animals to sexual activity, are essential data
Histoplasmosis
points. However, many critically ill patients cannot provide this history
Anthrax due to their severity of illness (obtundation, respiratory failure with
Plague mechanical ventilation, sedation, agitation) and thus, epidemiologic
investigations can be difficult in these settings.
Endemic typhus
East and Southeast Asia Acute diarrhea
Dengue TABLE 77-3 Incubation periods of common pathogens causing critical illness
Malaria (drug resistant) <10 Days 11-30 Days >30 Days
Influenza Dengue Malaria (falciparum) Malaria (falciparum)
Schistosomiasis (japonicum) Viral hemorrhagic fever Leptospirosis Schistosomiasis
Tick-born encephalitis Rickettsial disease Rickettsial disease Paragonimiasis
Melioidosis Yersinia Strongyloides Hepatitis A/E
Japanese encephalitis Influenza Hepatitis A/E
Anthrax Anthrax
Plague Hantavirus
SARS Melioidosis
Endemic typhus Legionella

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