Page 983 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

714 PART 5: Infectious Disorders

TABLE 77-4 Pathogens Causing Critical Illness in Travelers Organized by Exposure TABLE 77-5 Common Examination Findings of Diseases Associated
Exposure/Environment Associated Disease With Travel-Associated Critical Illness
Examination Finding Associated Disease(s)
Urban Dengue
Leptospirosis Lymphadenopathy HIV, rickettsial disease, plague, dengue
Rural Plague Hepatomegaly Malaria, hepatitis A/E, leptospirosis
Mosquitoes (R) Viral hemorrhagic fever Splenomegaly Malaria, dengue, trypanosomiasis
Dengue Jaundice Malaria, hepatitis A/E, leptospirosis, dengue, HIV, Lassa fever
Malaria Hemorrhage Dengue, viral hemorrhagic fevers, meningococcal meningitis,
Lassa fever, rickettsial diseases
Fleas, mites Plague
Endemic typhus Maculopapular Dengue, HIV, rickettsial disease, leptospirosis
Animal Rabies (street dogs, bats, cats, monkeys) Ecchymosis/petechiae Rickettsial disease, meningococcal meningitis, viral hemorrhagic
fever, leptospirosis
Plague (rodents, rabbits, animal carcasses)
Eschar Rickettsial diseases (scrub typhus), anthrax, African trypanoso-
Anthrax (carcasses, goatskins)
miasis, viral hemorrhagic fever
Herpes B virus (monkeys)
Ulcers Anthrax, plague
Hantavirus Urticaria Schistosomiasis
Influenza (birds)
Histoplasmosis (bats)
Endemic typhus (flying squirrel) ■ PHYSICAL EXAMINATION
Fly, ticks African trypanosomiasis In addition to extensive cardiopulmonary examination, great care
Rocky Mountain spotted fever should be given to examination of the reticuloendothelial system. In
addition, clues to diagnosis can be gleaned from thorough skin exami-
Sand/dirt Leptospirosis
nation for both rashes and animal or insect bites, as diseases causing
Coccidioidomycosis critical illness and dermatological findings are limited. 1,7,8,11,15 Table 77-5
Histoplasmosis outlines the major physical examination findings that are seen with
Fresh water swimming Leptospirosis certain disease syndromes in a traveler. But most importantly, travel-
Schistosomiasis related critical illness can be categorized into clinical syndrome, which is
essential in the early stages of empiric therapy or when a detailed epide-
Adventure travel/eco travel/hunting Leptospirosis miologic history is not obtainable. While there is overlap between many
Histoplasmosis (spelunking) of these syndromes and some pathogens are associated with more than
Schistosomiasis one syndrome, we believe this approach to be instrumental in further
Melioidosis delineating etiology of critical illness in the traveler. Table 77-6 outlines
1,7,8,11,15
these clinical syndromes and etiologic agents.
Rocky Mountain Spotted fever
IVDA/piercing/blood products/acupuncture HIV ■ INITIAL DIAGNOSTICS
Hepatitis A/E The wide array of diseases seen with worldwide travel makes early diagno-
Sick contacts Influenza sis difficult. Furthermore, many diseases are only diagnosed by serology
Meningococcus (hantavirus), or biopsy (tularemia), or specialized culture requirements
that make isolation difficult (Y pestis). These diagnostics also require
Viral hemorrhagic fever time, which can be difficult given the urgency of treatment of a critically
Influenza ill patient. 16-18 However, by focusing on the most rapidly lethal diseases
SARS of a traveler, particularly those with time-sensitive treatment regimens, a
Anthrax systematic approach to quick diagnostics and treatment can be reached.
Plague
Untreated water Hepatitis A/E TABLE 77-6 Syndromes of Critical Illness and Diseases Associated With Travel-
Acute diarrhea Related Critical Illness
Air travel Influenza Clinical Syndrome Associated Disease(s)
SARS Pneumonia/ARDS Hantavirus, SARS, pneumococcus, influenza, Legionella,
plague (pneumonic), melioidosis, Legionella, schistoso-
Cruise ship Legionella miasis, histoplasmosis, coccidioidomycosis, SARS
Unprotected sex HIV
Septic shock/multiorgan system Meningococcal meningitis, viral hemorrhagic fever, dengue
Flooding/natural disaster Leptospirosis failure hemorrhagic fever, pneumococcus, melioidosis, plague
Melioidosis Encephalitis/meningitis Meningococcal meningitis, dengue, Japanese encephalitis,
Endemic typhus African trypanosomiasis, rabies, viral hemorrhagic fever
Pilgrimage/Hajj Meningococcus Fulminant hepatic failure Hepatitis A/E
Pregnancy Hepatitis E Diarrheal illness, hemolytic Enterotoxic E coli
Construction Melioidosis uremic syndrome
Leptospirosis Necrotizing soft tissue infection Vibrio fulnificans, MRSA, Streptococcus pyogenes

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