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In the Clinic |

Travel Medicine

Brian S. Schwartz, MD; Regina C. LaRocque, MD, MPH; and Edward T. Ryan, MD
Ann Intern Med. 2012;156(11):ITC6-1. doi:10.7326/0003-4819-156-11-201206050-01006
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Primary care physicians are frequent sources of health advice for U.S. international travelers (1, 2). To properly prepare travelers, health care providers need to be familiar with destination-specific disease risks, travel and routine vaccines, chemoprophylaxis regimens, and self-treatment regimens for infectious and noninfectious illnesses. In addition, ill returning travelers may seek care in primary care settings, and these providers need to be appropriately prepared. Of note, the Centers for Disease Control and Prevention (CDC) maintains a Web site focused on travelers' health (www.cdc.gov/travel/) and regularly updates a publication entitled CDC Health Information for International Travel (i.e., The Yellow Book) (3). This book is also available online (wwwnc.cdc.gov/travel/page/yellowbook-2012-home.htm).

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travel ; traveler ; vaccines

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Malaria in a Traveler from Uganda
Posted on June 14, 2012
Luis A. Marcos, MD, MPHc. Infectious Diseases Specialist, Medical Director of Infection Prevention Department, Clayton Boothe. RPh, MS, Clin. Pharm. Coord.
Forrest General Hospital, Hattiesburg, MS, USA.
Conflict of Interest: None Declared
Dear Editor, We were pleased to read the work of Schwartz et. al. regarding travel medicine published in the last issue of your journal [1]. This information would be of great value for primary care providers about travel medicine recommendations especially on malaria prophylaxis since the disease can be prevented by taking the adequate prophylaxis therapy. We have seen a complicated case of malaria in a traveler from Uganda which stresses the importance of having value informative tools as published by Schwartz et al. [1]. A 24 year-old male missionary returned to the United States after a 1-month trip to Uganda complaining of high fevers, chills, profuse sweats, nausea and vomiting. On physical exam, he was pallid and mildly icteric. The tip of the spleen was palpable. In laboratory results, a mild anemia with hemoglobin level of 10.4 g/L was noted. A thin blood smear revealed classic ring forms of malaria parasites with 4% parasitemia. He was treated as uncomplicated malaria with mefloquine 750mg orally load and then 500mg repeated in 6 hours. Next day, fevers and headaches were persistent and more severe. Hemoglobin level dropped to 6.6 g/L and platelet count to 72,000 /mm3. A concern for severe malaria was entertained. Intravenous quinidine was not readily available. He was started immediately on quinidine gluconate 10mg/kg orally every 8 hours (available in our hospital) and doxycycline 100mg orally twice daily. The next day, he was still febrile but his blood smear revealed a decrease on the parasitemia to 2%. On the third day of treatment, parasitemia was 0.1%. His symptoms and the fever resolved after treatment day 3. He completed a 3-day course of quinidine gluconate and a 7-day course of doxycycline. No other complications were noted and he was discharged home. The treatment was a challenge because the patient's clinical picture deteriorated during the first 24 hours of treatment. Quinidine oral tablet was the only immediately available drug for severe malaria in our hospital. It is well know that quinidine is preferred in falciparum malaria over quinine (IV form not available in the US) because the minimum inhibitory concentration for P. falciparum is lower for quinidine than for quinine; making the latter less effective against P. falciparum [2]. Patient was reported to be using chloroquine for malaria prophylaxis during the missionary trip. According to the CDC malaria map application, Uganda has malaria species resistant to chloroquine so recommended prophylaxis is atovaquone/proguanil, doxycycline or mefloquine [3]. The Ministry of Health in Uganda has stated that P. falciparum is responsible for more than 90% of malarious cases in their country and about 95% of the territory is exposed to moderate to very high transmission levels [4]. Thus, there was very likely that our patient was infected by P. falciparum. Despite him taking chloroquine without omitting any doses during his 2-week charity mission trip, he developed the disease because he was in a chloroquine-resistant malaria area. Current interactive tools are available at the CDC malaria map application website [3], which is very useful as additional informative tool to identify those areas with drug-resistance to malaria such as Africa (chloroquine-resistance) and other parts of the world where more than one drug has already been reported as resistant to malaria such as chloroquine and mefloquine in Southeast Asia. In light of the increasing missionary, charity, medical, vacation and business trips to developing countries; more travel medicine clinics may be needed for specific travel recommendations. Malaria is a worldwide problem. In 2008, about one million people died of malaria, most of them young children in sub-Saharan Africa [5]. It is also not infrequent seen malaria in travelers who take adequate, but incomplete, prophylaxis such as the case of P. vivax in a soldier by not taken terminal primaquine after doxycycline [6]. Malaria is a common disease in tropical countries and travelers are at risk of acquiring this infection, this risk can be decreased significantly by taking an adequate prophylaxis therapy which can ultimately prevent severe morbidity as in our case. Finally, travel medicine clinic advice is recommended to travelers and these are needed even in medium to small cities in high-income countries given the increasing number of people travelling globally. References1. Schwartz BS, Larocque RC, Ryan ET. Travel medicine. Ann Intern Med. 2012 Jun 5;156(11):ITC61.2. White NJ, Looareesuwan S, Warrell DA, Chongsuphajaisiddhi T, Bunnag D, Harinasuta T. Quinidine in falciparum malaria. Lancet 1981;2:1069-71. 3. CDC malaria map application, accessed on June 09, 2011. http://cdc-malaria.ncsa.uiuc.edu4. Uganda Malaria Control Strategy 2005/06 – 2009/10. Malaria Control Programme. Ministry of Health. Electronically accessed on June 09, 2012. http://www.rbm.who.int/countryaction/nsp/uganda.pdf5. Malaria CDC. electronically accessed June 6, 2012. http://www.cdc.gov/MALARIA6. Hagan JE, Marcos LA, Steinberg TH. Fever in a soldier returned from Afghanistan.J Travel Med. 2010;17(5):351-2
Malaria in a Traveler from Uganda
Posted on August 9, 2012
Luis A. Marcos, MD, MPHc, Infectious Diseases Specialist, Medical Director of Infection, Clayton Boothe, Clinical Pharmacist
Prevention Department, Forrest General Hospital, Hattiesburg, MS, USA.
Conflict of Interest: None Declared

Dear Editor, The aim of this letter is to alert primary care providers about malaria prophylaxis by presenting a traveler who developed malaria after a trip to Africa. A 24 year-old missionary man returned to the United States after a 1-month trip in Uganda complaining of high fevers, chills, profuse sweats, nausea and vomiting. On physical exam, he was dehydrated, pale, mildly icteric and the tip of the spleen was palpable. In laboratory results, only a mild anemia with a hemoglobin level of 10.4 g/L was noted. A thin blood smear revealed classic ring forms of malaria parasites with 4% parasitemia. He was treated as uncomplicated malaria with mefloquine 750mg orally once and then 500mg repeated in 6 hours. Next day, fevers and headaches were persistent and more severe. Hemoglobin level dropped to 6.6 g/L and platelet count to 72,000 /mm3. A concern for severe malaria was entertained. Intravenous quinidine was not readily available. He was started immediately on quinidine gluconate 10mg/kg orally every 8 hours (available in our hospital) and doxycycline 100mg orally twice a day. Next day, he was still febrile but his blood smear revealed a decrease on the parasitemia to 2%. On the third day of treatment, parasitemia was 0.1%. His symptoms and the fever resolved after the 3rd day of therapy. He completed a 3-day course of quinidine gluconate and a 7-day course of doxycycline. No other complications were noted and he was discharged home. The treatment was a challenge because the patient's clinical picture deteriorated during the first 24 hours of treatment. Quinidine orally was the only immediate available drug for severe malaria in our hospital. It is well know that quinidine is preferred in falciparum malaria over quinine (not available in the US) because the minimum inhibitory concentration for P. falciparum is lower for quinidine than for quinine; making the last less effective against P. falciparum [3]. Patient was taken chloroquine for prophylaxis against malaria during the missionary trip. According to the CDC malaria map application, Uganda has malaria species resistant to chloroquine so that the recommended drugs for prophylaxis are atovaquone/proguanil, doxycycline or mefloquine [1]. The Ministry of Health in Uganda has shown that P. falciparum is responsible for more than 90% of malarious cases in this country and about 95% of the territory is exposed to moderate to very high transmission levels [2]. Thus, there was very likely that our patient was infected by P. falciparum. Despite he was taking chloroquine without missing any dose during his 2-week charity mission trip, he developed the disease because he was in a chloroquine-resistant malaria area. Current interactive tools are available at the CDC malaria map application website [1], which helps to identify those areas with drug-resistance to malaria such as Africa (chloroquine-resistance) and other parts of the world where more than one drug has already been reported as resistant to malaria such as chloroquine and mefloquine in Southeast Asia [1]. In light of the increasing missionary, charity, medical, vacation and business trips to developing countries; more travel medicine clinics may be needed for specific travel recommendations. Malaria is a worldwide problem. In 2008, about one million people died of malaria, most of them young children in sub-Saharan Africa [4]. It is also not infrequent seen malaria in travelers who take adequate, but incomplete, prophylaxis such as the case of P. vivax in a soldier by not taken terminal primaquine after doxycycline [5]. Malaria is a common disease in tropical countries and travelers are at risk of acquiring this infection, this risk can be decreased significantly by taking an adequate prophylaxis therapy which can ultimately prevent severe morbidity as in our case. Finally, a travel medicine clinic advise is recommended to travelers and these are needed even in medium to small cities in high-income countries given the increasing number of people travelling around the world.

References

1. CDC malaria map application, accessed on November 29, 2011. http://cdc-malaria.ncsa.uiuc.edu

2. Uganda Malaria Control Strategy 2005/06 – 2009/10. Malaria Control Programme. Ministry of Health. Electronically accessed on February, 2012. http://www.rbm.who.int/countryaction/nsp/uganda.pdf

3. White NJ, Looareesuwan S, Warrell DA, Chongsuphajaisiddhi T, Bunnag D, Harinasuta T. Quinidine in falciparum malaria. Lancet 1981;2:1069-71.

4. Malaria CDC. electronically accessed June 6, 2012. http://www.cdc.gov/MALARIA

5. Hagan JE, Marcos LA, Steinberg TH. Fever in a soldier returned from Afghanistan.J Travel Med. 2010;17(5):351-2

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