Rashes From Around the World

(+)Rachel L. Chin, MD, FACEP
Professor, Emergency Medicine;
Attending, Emergency Services, San
Francisco General Hospital, University of
California San Francisco, School of
Medicine, San Francisco, California
Rashes From Around the World
As our world becomes smaller with frequent transcontinental
flights, more and more patients from foreign lands are
coming to our EDs with skin conditions common to where
they came from, but not common to the US. In addition,
increasing numbers of emergency physicians are going on
international medical missions. Learn how to identify and
treat common and potentially life-threatening skin conditions
from around the world.
• Identify common and life-threatening skin conditions
from outside the United States.
• Describe the treatment of these skin conditions.
MO-62
Monday, October 5, 2009
4:00 PM - 4:50 PM
Boston Convention & Exhibition Center
(+)No significant financial relationships to disclose
Rashes from Around the
World
The Burden of Illness in
International Travelers
  Annually, there are ~ 800 million travelers
•  100 million to the tropics
•  50 million American travelers (8% to tropics)
•  About 50% are vacationing
  22-65% report some illness
Rachel L. Chin M.D. FACEP
Professor of Emergency Medicine
University of California, San Francisco
San Francisco General Hospital
The Burden of Illness in
International Travelers
Dupont HL. TACCA 2008; 119: 1-27; Freedman DO, et al. NEJM 354:21
2006.; Hill DR. NEJM 2006; 354(2): 115-17
How do you Approach the Patient?
“TRIPS”
  8% seek care
•  ~60% within 1 month of return
•  up to 10% after 6 months
  The risk of travel-related illness goes up by
3-4% per day of travel
  But…less than 50% seek pre-travel advice
•  Even less in those visiting friends and relatives
Assessment – History
“TRIPS”
  Travel itinerary
•  Date of travel and return
•  Countries visited and regions within countries
•  Get an atlas or map if unsure
  Purpose of visit
  Accommodation
The Importance of Geography: The
GeoSentinal Surveillance Network
“TRIPS”
  40 centers in 6 continents
  CDC + ISTM
•  Febrile illness (sub-Saharan Africa or SE Asia)
•  Acute Diarrhea (south central Asia)
•  Dermatologic problems (Caribbean or Central or South America)
Freedman DO. Spectrum of Diseases and Relation to Place of Exposure
among Ill Returned Travelers. NEJM 354;21 2006
1
What are the Major Diseases?
  Travelers’ diarrhea
(ETEC>15% total) 20-60%
  Malaria
10%
  Influenza A or B
1%
  Incidence rate per month of
health problems during a
stay in developing countries
- 2008
Journal of Travel Medicine Vol. 15, 3: 145-146
Assess for Risks and Specific
Exposures
Dermatologic conditions of the ill returned
traveler: an analysis from the GeoSentinel
Surveillance Network
  Arthropod-related (insect bite, dengue, cutaneous
leishmaniasis)
30.9%
  Unknown
14.6%
  Pyodermas (skin abscess, cellulitis, erysipelas)
12.8%
  Soil-related (CML, tungiasis)
10.5%
  Animal-related (dog bite, monkey bite, other animals) 9.3%
  Allergic in nature
5.5%
  Human to human (scabies, leprosy, syphilis, varicella) 4.8%
  Fungal rash
4.4%
International Journal of Infectious Diseases 12:6 2008
Likelihood of Diagnosis Based on
Incubation Period
“TRIPS”
  Animal? (rabies)
  Insect? (malaria, dengue, tick-bite fever)
  Water? (schistosomiasis, leptospirosis)
  Consumption of food, water (enteric)
  Other ill travelers? (influenza, SARS)
  Sexual activity? (acute HIV)
  Unusual (spelunking, EcoChallenge)
Adapted from Ryan ET, et al. Illness after International Travel. NEJM 2002; 347: 7
Central Mexico
History
  32-year-old man developed sudden onset of
headache, high fever, and extreme fatigue
two days after returning from a summer
vacation in Central Mexico.
  Complained of a flushing over the face and
chest and “sore eyes”.
  Three days later, developed a generalized
“splotchy” rash.
2
Additional History
 
 
 
 
 
 
 
Traveled in Mexico for 9 days
Admits to mosquito exposure, denies tick exposure
Denies any animal, water, food exposures
Single sexual encounter
Vaccines – Hep A, typhoid
Anti-malarial prophylaxis –denies
Up to date on routine childhood vaccines
How do you approach the patient?
“TRIPS”
9 days
Fever, sore eyes,
splotchy rash
None for malaria
Physical Exam
Mexico
Sex, mosquitoes
11 days
Additional Findings
  VS: 38.8, 110/65, 87, 18, 98%/RA
  GEN: comfortable appearing, NAD
  HEENT: oropharynx clear
  NECK: supple, no meningismus
  CV: tachy no murmur
  CHEST: clear
  ABD: benign, no HSM
  DERM: diffuse maculopapular rash, scattered
petechiae
  CBC: 1.5 >48.9<37
  Creatinine-0.9
  AST -124 ALT -87
Alk phos, bili wnl
  PT, PTT wnl
Dengue Fever
  Virus: Family
Flaviviridae, four
serotypes
  Vector: Aedes aegypti
and Aedes albopictus
mosquitos
  Incubation: 4-7 days
(3-14 days)
•  66% with dengue
seen w/in 1wk
3
  Clinical Manifestations
•  Fever
•  Severe headache, often
described as retro-orbital
•  Myalgias and arthralgias
(“break-bone fever”)
•  Nausea and vomiting
•  Rash -Generalized erythema
->maculopapular w/ petechiae
•  Hemorrhagic Fever,
Hemorrhagic shock syndrome
(prior exposure)
  Lab abnormalities Leukopenia,
thrombocytopenia,
transaminitis
Dengue Hemorrhagic Fever
 Complications: DSS/DHF
• Rare in travelers
• Observed more often in children
Diagnostics
  Blood culture x 2 –No growth
  CXR -clear
  Thick and thin smear -negative
  HIV –negative
  Dengue virus titers -IgM11.78, IgG< 0.5
  Clinical dx, and confirm with rise in serum
antibody titers.
  Endemic area
  Positive tourniquet sign
Dengue Fever
  Recent increase in dengue risk area
  Estimated 100 million cases annually
•  25,000 deaths
  Seasonal epidemics are common in tropical and
subtropical countries
  High transmission rate in urban areas
•  Current outbreak in Brazil with 120,570 cases ( Rio de
Janeiro, Singapore, Puerto Rico, and Hawaii)
•  Increasing problem in central and S America
  Most common cause of fever in travelers to the
Caribbean, South America and South Asia
Gibbons
RV,
Vaughn
DW.
BMJ
2002;324
Treatment
South Africa
Case #2
  Supportive
•  After the rash appears the temperature begins to
fall and recovery begins
•  Avoid NSAIDS, can use tylenol
4
History
  43 year-old male with no PMH returns from a
10 day vacation to South Africa with
complaints of fever, myalgias, and rash.
Additional History
  Big game hunt -denied animal bites
  Denies contaminated water, food, or sick
contact exposure
  Vaccines
•  Yes –Hep A, Typhoid
10 days
  Anti-malarial
South Africa
fever, myalgias,
Big game hunt
prophylaxis
rash
•  Yes -Atovaquone/
proguanil (malarone)
yes
10 days
Physical Exam
  VS. 38.5, 76, 128/70, 16, 99% RA
  HEENT, CV, Pulmonary, Abdominal, Extremity
exams -WNL
  Lymph –1 cm R inguinal LAD, minimal tenderness
  DERM –right waistband region, 1.5 x 1 cm ulcer w/
mild surrounding erythema non-painful; approx 20 0.2-0.3 cm papulo-vesicular lesions on trunk, flank,
back, forehead, arms, and legs
Labs and Microbiology
Diagnosis:
African tick bite fever (Rickettsia africae)
  Travel to Sub-Saharan Africa -#2 cause of
febrile illness –rickettsial disease
  Exposure –direct contact with wild animals
(which often carry ticks), camping, hiking or
safari in grass/scrubby area
  Incubation period -< 11 days
  Exam -fever, eschar, papulovesicular rash
  May get leukopenia, and/or thrombocytopenia
5
Important diagnostic clue
  Eschar - painless
necrotic or crusted
lesion at site of tick
bite with some
surrounding
erythema
African Tick Bite Fever
Transmission
  Ambylyomma ticks
•  Aggressive (often multiple
bites)
•  Cattle, sheep, donkeys, wild
ungulates (giraffes, buffalo,
etc..)
•  Need at least 20% DEET,
but only 2h of efficacy
•  Southern African bont tick
•  Amblyomma hebraeum
•  70% infected w/ R. africae
Treatment
Thailand
Case #3
  Doxycycline 100 mg BID x 7 days or until 48
hour after defervescence
  Symptoms often improve 24-48h after
initiation of treatment (fast recovery is
diagnostic)
CASE # 3
History
Clinical Findings
  56 yo female complains of fever, severe joint
pains, and rash 4 days after returning from a
trip to Thailand in January.
  Took malaria prophylaxis, vaccines
  No other known exposures
  Maculopapular rash, distal tender swollen
joints on exam
  Mild leukopenia and thrombocytopenia
Simon F, et al. Medicine 2007; 86(3): 123-137
6
Chikungunya in Travelers
Chikungunya in Travelers
  A word from the Bantu language of Mozambique and
Tanzania means “that which bends up” referring to
the stooped posture that develops as a result of
arthritic symptoms
  Clinical Triad: fever, rash, and arthropathy
  Elderly at higher risk
  Severe polyarthralgia, symmetric
  Largest outbreak March 2005-April 2006 ~
255,000 cases in Reunion, French territory in
the Indian Ocean (total population ~ 770,000)
  End of 2006 ~ 1.5 million cases in 7 countries
  Transmitted by Aedes aegypti and Aedes
albopictus.
Taubitz W, et al. “Chikungunya fever in travelers:clinical presentation and
course”; CID 2007; MMWR, March 30, 2007;56(12)
Chikungunya
India
Case #4
  Found in Asia, Africa, and the Indian Ocean (not
Americas and the Caribbean)
  Clinical symptoms similar to dengue fever but diffuse
arthralgias/arthritis is more predominant
  Dx: clinical and Chikungunya virus specific IgM and
/or IgG antibodies
  Treatment: symptomatic
•  Cyclooxygenase inhibitor - ibuprofen
•  Chloroquine effective (but no controlled studies)
Case #4
Macular lesions
(“Rose Spots”)
  A family returned from India 1 week ago complaining
of fever, malaise, abdominal pain with constipation
and a rash. They lived with an Irish cook named
Mary.
7
Typhoid Fever
Enteric fever
  Salmonella typhi
  Salmonella paratyphi
(A,B,C)
  Transmission
contaminated food,
water
  Reservoir of infection asymptomatic human
carriers (fecal & urinary)
  Cases 16 million/yr
  Deaths 600,000/year
  Pre-antibiotic era
15% case fatality,
now <1%
  Incubation about
7-14 days
  Fever, rash,
abdominal pain
•  Constipation more
common than
diarrhea
Rose spots (30%)
Temperature chart of
untreated typhoid fever
Enteric fever
  Complications –typically in 3rd week in untreated
infection
  GI hemorrhage, perforation
  Pneumonia
  Myocarditis
  Meningitis
  Osteomyelitis
  Focal abscesses
  Relapse -increased frequency in HIV
Peters and Pasvol: Atlas of Tropical Medicine and Parasitology 6th Ed. Elsevier Ltd
Enteric fever
  Diagnosis –isolation from sterile site
•  Blood, stool, or urine cultures
•  A bone marrow culture often is the most sensitive
test for S. typhi.
  Blood results
•  Leucopenia, mild thromboctopenia
•  Moderate elevation of ALT
Typhoid fever
  Treatment: Fluoroquinolones
  Drug resistance
•  MDR S. typhi (amp, trim, sulfa, tet) in 35% from India, 80%
Vietnam
•  FQ resistance widespread in India
  If FQ-resistant consider Ceftriaxone or Azithromycin
  2 vaccines
•  Ty21a –live attenuated oral, ≥6 years of age, 4 doses
completed at least before 1 week of travel
•  ViCPS–parenteral capsular polysaccharide, ≥2 years of age,
1 dose at least 2 weeks prior
•  50-80% effective
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Caribbean
Case# 5
A 35 year old man returning from a
Caribbean beach vacation has a pruritic
rash on his foot with a serpentine
appearance. What is the diagnosis?
1. Schistosomiasis
2. Cutaneous larva
migrans
(hookworm)
3. Echinococcus
Multilocularis
(tapeworm)
4. Jellyfish sting
5. Swimmers itch
Cutaneous larva migrans
“Creeping eruption”
  Etiology: infective stage
(larvae) of the dog or cat
hookworm, Ancylostoma
braziliense
•  Hookworm passed in
feces, hatches in soil
or sand, penetrates
human skin and
migrates superficially
several mm/day.
•  Feet, buttock more
common.
Belize
Case #5
Cutaneous larva migrans
  Pruritic papules, then
serpiginous lines
  Tropical/subtropical beaches
  Lasts for weeks to months if
not treated
  Pulmonary involvement can
occur
–Less common
–Dry cough, fleeting
infiltrates, eosinophilia
  Rx with ivermectin or
albendazole.
Case #5
  44 yo male returned from Belize with the
complaint that “things are crawling under my
scalp”. No itching. No other unusual skin
lesions. No psychiatric history. MD friend
gave him Keflex for skin infection-no help
  PE: 6 raised red papules scattered over top of
head. No discharge, but visible central
opening , approximately 2 mm on each.
9
Myaisis
  Caused by invasion of the skin by Fly larvae
including:
•  Human Botfly
•  African Tumbufly
  Humans are usually accidental hosts
Invasion of the Body Snatchers
Human Botfly Larva
  Widely distributed in Central and South America
  Eggs reach a suitable host by gluing onto the
abdomen of a biting insect, thereby getting
inserted to host on puncture.
  Resembles a boil-like lesion with a punctate air
hole
  African Tumbufly larvae can bore directly, no
intermediary mosquitos needed ( laundry issues)
Cutaneous Myiasis
TUMBU FLY
African Tumbu Fly Larvae
  TUMBU FLY: –
•  Sub-saharan Africa
and southern Spain.
•  Usually on tourist who
hung clothes out to
dry, flies can lay eggs
on the clothes.
•  Painless penetration of
skin. Usually serous
drainage with
occasional regional
lymph node
enlargement.
BMC Surgery 2004, 4:5
10
Treatment
Treatment
BACON BRA
  Surgical removal
  Occlusive techniques
•  Vaseline
•  1-2 strips of uncooked bacon placed over the air
hole overnight
  Commercial venom extractor
  Squeeze
Tanzania
Case #6
Case #6
Fever and skin lesion following travel to
Tanzania
Emerging Infectious Diseases
2002;8(1)
Trypanosomiasis in travellers
African trypanosomiasis
–infection in humans
  T brucei rhodesiense/gambiense –
African
  Exposure: game parks
  Vector: tsetse fly
  Humans only infected incidentally
•  Increased incidence in tourists
•  Wild animals are usual reservoir.
11
Trypanosomiasis
“Sleeping Sickness”
Trypanosomiasis
  Ulcerated chancre plus lymphandenopathy returning
from sub-saharan Africa
  Recurrent fever with variable onset of CNS symptoms
  Rare cause of illness
  Symptoms: chancre
  Gambian form: intermittent fever, HA, myalgias for
mos. to yrs.
  Rhodesian form: more acute
  CNS: progressive somnolence, occasional meningitis
and focal neurologic symptoms
  Diagnosis: demonstration of parasites, motile
trypanosomes seen in serous fluid expressed from
chancers, aspirates of lymph nodes, Giemsa stained
thick blood smear.
  Treatment: Gambinese
  Early Melarsoprol-nifurtimox
  Late efloritine
  Rhodesiense
  Early stage: suramin
  Late stage: melarsorol
Trypanosomiasis
Lake Malawi in Mozambique
  Trivia: eflornithine in
US used for
restoring baldness
with side benefit of
treatment of orphan
drug
  Untreated disease
leads to death in
weeks/months
  11 exchange
students from
London visiting
Malawi complains
of itchy skin rash
and “flu-like”
symptoms after
swimming in Lake
Malawi.
Acute Schistosomiasis
(Katayama Fever)
  Schistosomiasis prevalent throughout
sub-Saharan Africa and
parts of south east
Asia.
  Fresh water that
harbors intermediate
snail host
Acute Schistosomiasis
(Katayama Fever)
  2-8 weeks after exposure
  Rash
  Fevers, headache, myalgia, malaise
  Lymphadenopathy and eosinophillia
12
Acute Schistosomiasis
(Katayama Fever)
  Pathogenesis is
unknown, immune
complex?
  Schistosomal
myelopathy may result
in neurological
problem.
  Treatment: praziquantel
Swimmer’s Itch
Cercarial Dermatitis
Avian schistosomes
  Swimmer’s Itch, duck
itch, schistosome
cercarial dermatitis,
  Fresh water
  Schistosomal cercariae
invade epidermis
  Exposed skin only
Swimmer’s Itch
Cercarial Dermatitis
  Evanescent
erythematous
macules followed
by pruritic papules,
vesicles, pustules
  Self-limited, 10-14
days
  Symptomatic
therapy
Summary
  “TRIPS”
  Detailed history
  Risk assessment –isolate patient if unsure
  Importance of incubation periods
  Knowledge of common tropical infections
  Diagnostic tests
  Seek specialist help
Other preventive advice
  Environmental exposures
•  Avoid walking with bare feet • hookworm, strongyloides, CLM
•  Avoid fresh water exposure • schistosomiasis, leptospoirosis
  Avoid animal bites or scratches
•  Don’t feed, pat, play with animals (rabies)
  Decreased risk-taking behavior during travel
•  Advice re safe sex/condoms
•  Advice re substance abuse, alcohol
•  Injury prevention
•  Wear seat belts, avoid motorcycles, wear helmets etc
•  Don’t swim when drunk
•  Don’t walk alone in remote areas, lock/hide valuables
13
Travel Resources
Thank You
Questions?
  CDC: http://wwwn.cdc.gov/travel/default.aspx
  WHO: http://www.who.int/ith/en/
  Other:
• 
• 
• 
• 
http://www.MDtravelhealth.com
http://www.traveldoctor.info/
https://www.tripprep.com/scripts/main/default.asp
http://www.fitfortravel.nhs.uk/
Crapstone, UK
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