UMEM Educational Pearls - International EM

Diagnosis should be considered in any individual over 5 years old with severe dehydration from diarrhea, regardless of exposure to an endemic area, and any patient over 2 years old with watery diarrhea in an endemic area. 

Patients with severe cholera can stool as much as 1 L an hour.  Replacing fluids is the most important part of treatment with oral rehydration being used as soon as possible.  Oral rehydration therapy  provides better potassium, carbohydrate, and bicarbonate replacement than most IV fluid solutions.  Antibiotics will also decrease volume and duration of stooling but are only recommended in moderate to severe illness.  Antiemetics are not useful because they can make patients sleepy and will reduce their ability to rehydrate orally.  Antimotility medications will prolong the duration of illness. 

University of Maryland Section for Global Emergency Health

Author:  Jenny Reifel Saltzberg

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• Causative organism: members of the genus Borrelia
  • Louse Borne Relapsing Fever (LBRF)
    • Human body louse (Pediculus humanus)
    • Associated with sporadic outbreaks especially in areas with large refugee populations
  • Tick Borne Relapsing Fever (TBRF)
    • Soft ticks of the genus Ornithodoros
    • Typically found in higher elevations of the western United States as well as the central plateau region of Mexico, Central and South America and Africa
• Clinical Presentation
  • Symptoms develop 3 to 18 days after infection.
  • Onset is abrupt and may include fever, malaise, headache, arthralgias, nausea and vomiting and cough.
  • The first febrile episode lasts 3 to 6 days and then recurrences may occur after 7 to 10 days.
• Diagnosis
  • Definitive diagnosis: visualization of spirochetes on peripheral blood smear.
  • May also see leukocytosis, anemia and/or thrombocytopenia, elevation of liver function tests
  • Erythrocyte rosette formation may be present.
• Treatment
  • Antibiotics recommended for treatment include penicillin, doxycycline and erythromycin.
  • Jarisch-Herxheimer reaction common after treatment. This can be life threatening and all patients undergoing treatment should be closely monitored.

University of Maryland Section for Global Emergency Health

Author: Gentry Wilkerson

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Case Presentation:

53 yo male presents with fever, myalgia, maculopapular rash, and severe polyarthralgia. He just returned from a cruise to the Caribbean islands.

Clinical Question:

What is the diagnosis?

Answer:

Chikungunya Virus

• Travelers who go to the Caribbean are at risk of getting chikungunya. Cases have been reported in Saint Martin, Martinique, and Guadeloupe. In addition, travelers to Africa, Asia, and islands in the Indian Ocean and Western Pacific are also at risk.
• Mosquito vector, incubation 3-7 days
• Joints involved are typically hands and feet, usually symmetric, severe arthralgia often debilitating
• Dx: serology - ELISA, IgM
• Treatment: IVF, NSAIDS, supportive

Bottom Line:

• Include Chikungunya in your differential of non-specific fever, rash, headache and arthralgia in travelers the Caribbean and endemic areas.

University of Maryland Section of Global Emergency Health

Author: Veronica Pei, MD

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