A patient had been referred into hospital because they had a very high temperature, severe muscle and joint pains and headache, she has recently returned from a holiday in Thailand. The patient had attended a pre-travel clinic, been given the appropriate vaccinations including for typhoid and had taken her Malaria prophylaxis. When she was seen on the ward she had developed a rash on her chest. The team thought the patient might have typhoid or paratyphoid (the vaccine is 70% effective for typhoid but has no effect on
paratyphoid). They had excluded malaria with blood tests, which is an essential component of the management of any traveller with a fever who has returned from a country where malaria is endemic. The patient’s blood tests showed a profoundly low white blood cell count and a slightly low platelet count. The patient’s kidney and liver function was within normal ranges.
The patient had been initiated on treatment for typhoid and paratyphoid with Ceftriaxone (NB. Ciprofloxacin is no longer use first line because resistance rates can be as high as 85%) but it was more likely that the patient had acquired
Dengue, which is endemic in Thailand. Serology tests confirmed Dengue and the patient received supportive care with intravenous fluids and Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) for the fever and pain until their symptoms started to resolve and their blood tests improved. Dengue was a self-limiting infection in this case, however as this patient would probably testify it makes you feel very unwell…it’s not known as break bone fever for nothing. Break bone fever was a name applied in the past before the cause of Dengue was known, and referred to the severe muscle and joint pains that made patients feel that their bones were literally breaking!
time you get a new serotype the severity is worse. In its most severe form the patient can develop Dengue Haemorrhagic Fever (DHF) where they start to bleed,
develop multi-organ failure, shock and widespread oedema, ultimately leading to death. In western medicine the mortality rate of DHF is up to 5%.
The case highlights the need for travellers not only to take medication appropriate for their destination e.g. vaccinations and malaria prophylaxis but also implement the prevention advice regarding exposure to potential infections e.g. from insects, animals and activities. Avoidance of mosquito bites is equally essential to prophylaxis; using insect repellents, mosquito nets, long sleeved shirts and long trousers as well as avoiding going out in heavily infested areas at dusk when mosquitoes are active and feeding. The case also highlights the need for a full travel history and investigation into the
infections endemic to the areas visited in order to reach the correct diagnosis.
As I said I am a big fan of foreign travel when sensible precautions are taken...I depart for a trip to northern Thailand trekking and elephant mahout training in November...!