Mediterranean cruise death and tick fever

http://www.flickr.com/photos/niosh/2492010385/A recent letter to the editor of Emerging Infectious Disease (EID), published by the CDC, discusses a case of Israeli Spotted Fever as the cause of death in a traveler who cruised the Mediterranean.  The article citation and link can be found here:

Boillat N, Genton B, D’Acremont V, Raoult D, Greub G. Fatal case of Israeli spotted fever after Mediterranean cruise [letter]. Emerg Infect Dis. 2008 Dec; [Epub ahead of print]

For those of you reaching for a textbook, let me save you some time…I already had to look it up. 

Basics:  Caused by Rickettsia conorii (sub-species israelensis) and closely related to Mediterranean Spotted Fever, this bacteria is intra-cellular and gram negative.  Spread by the bites of infected ticks, lice and fleas,  common symptoms include fevers, rash, bleeding from nose, hepatomegaly and a eschar at the site of the initial bite.  This is typically a self-limited disease and has fatality rate of < 3%, even without treatment.

Location:  Worldwide, with region specific illness (and nicknames) common.  Examples include Mediterranean Spotted Fever, South African tick-typhus, tsutsugamushi and many others.

Transmission/Prevention:  Transmitted though the bite of an infected tick, body lice, or chigger.  Rocky Mountain Spotted Fever (RMSF) is transmitted through the tick Dermacentor variabilis or D. andersoni.  Prevention is basic sanitation, prevention of bites through permethrin treated clothing and frequent tick-checks.

Diagnosis:  serology/pcr

Treatment:  Antibiotic treatments include doxycycline, typically for 5-7 days or 48 hours after a patient is afebrile. 

The case report notes that the patient died, even with adequate treatment.  The authors also pointed out that delayed antibiotics (6 days) could have been a factor in this unusual cause of mortality.

The location where this illness was contracted is also another question.  His trip took him through Crete, Libya and Malta.  Again, the authors speculate that he acquired the infection in Libya, where he spent several days touring the ruins of Appolonia, Sabratha and Ptolemais.  The incubation period of 7-8 days places him in Libya, prior to onset of symptoms.  Death was eleven days after the initial symptoms and occurred in Switzerland.

This article hopefully reminds everyone to think about a rickettsial disease in a febrile traveler, especially with a rash.  No history of a tick bit or insect bite was noted, in this case.  Frequent tick-checks can also be helpful and a source of bonding with your travel companions.  These insects seem to like areas of the body where hair grows.

CDC Tick Borne Diseases

Spot Satellite Messengers

spot-satellite-messengerOutside Magazine just posted their list of the coolest gear in 2008.  I was happy to see the Spot Satellite Messenger listed in there, with ultralight jackets and stoves.

This is a device that offers almost world-wide coverage and allows you to send a “HELP” signal to people’s mobile phones, e-mail or a emergency call center.  Use of GPS satellites ensures that help finds you, too!  There is even an option to allow your friends to track your progress, by viewing your trip map on the internet. 

Basic service plans start at about $100/year and you can add the option of sending messages, notifying people of your arrival to a destination, for a bit more. 

This is a very cool idea, to me.  Fortunately, there are still places in the world that a mobile-phone signal doesn’t reach, yet.  This little device provides some extra security for those looking to “get remote”.

US Army declares war on Dengue

http://en.wikipedia.org/wiki/Image:Aedes_aegypti_biting_human.jpgAn article covered by Medical News Today discusses the US Army and its attempts to control Dengue Fever, by attacking the mosquito that carries the disease.

Basics: Dengue is also known as “breakbone fever” after the muscular aches and myalgia it causes. An Arbovirus, transmitted by the bite of the Aedes mosquito, Dengue comes in 4 serotypes numbered 1-4. Found worldwide, this single stranded RNA virus is most closely associated with urban transmission. Infection may progress to Dengue Hemorrhagic Fever(DHF) and the risk of DHF increases with each subsequent infection. Typical symptoms include fever, severe muscle aches and fine petechial rash.

Location: Tropics worldwide, more common in urban settings

Transmission/ Incubation: transmitted by A. Aegypti in cities and A. Albopictus in jungles. Incubation is generally 5-10 days.

Prevention: Mosquito and vector control, topical DEET spray and permethrin treated clothing and bed nets.

Diagnosis: Serology/PCR

Treatment: Supportive Care including antipyretics, pain control and IV fluids

Dengue fever is a viral illness that is carried by Aedes mosquitoes. There is no treatment and no vaccine against this disease, nicknamed “breakbone fever” due to the body aches and pains associated with the disease. This infection is found in virtually all tropical countries, around the world and is a major source of mortality, especially in children. Complications of Dengue can include progression to “dengue hemorrhagic shock” where there is massive bleeding.

The Army’s plan is to make use of technology designed by SpringStar Inc, which is basically an innovative mosquito trap. The Aedes mosquito lays it’s eggs in standing water, such as water basins, old tires and virtually anything else that can hold water. The trap takes advantage of the fact that the mosquito likes to lay it’s eggs on the sides of the water, not in the middle. Using this information, a tiny (one millionth of a kilogram) dose of insecticide can be placed in the area where the eggs are to be laid. Thus, killing the mosquito and preventing massive local contamination of harmful “bug poison”.

Annually, Dengue infects 20-50 million people worldwide, with 15-20,000 deaths per year. One estimate also puts 2.5 billion people at risk for infection with Dengue fever. This is also considered the third most important infectious disease that effects US military troops, abroad.

Rabies victim survives

I am currently suffering through two weeks of “night float” which gives me an unfortunate amount of time to spend trapped in a tiny “on-call” room with poor internet access. I was able to find this very interesting story about a 15 year old boy, in Brazil, who survived rabies!

Rabies is a viral illness that is fatal in almost every case. Very, very few people survive a case of rabies and this just shows the importance of those “rabies shots” after being bitten by an animal. There is also a vaccine to prevent rabies and it should be strongly considered by travelers to remote areas or those who handle animals. Unfortunately, there is an international rabies vaccine shortage and you can read more about this over at Dr. Auerbach’s blog.

Back to the boy in Brazil, who actually survived his infection. The boy was treated using a protocoldeveloped at the Medical College of Wisconsin and nicknamed “The Milwaukee Protocol”. Previously developed, this combination treatment of anti-virals, sedatives and anaesthesia, saved the life of a young girl in Milwaukee.

The MSNBC article mentions that the boy becomes on of the three confirmed cases of rabies to survive, ever. The physicians involved with his care are planning to publish.

http://www.msnbc.msn.com/id/27720513/

Travel Medical Kit at CheapOair

A very nice post about a traveler’s medical kit can be read over at the CheapOair site:

http://cheapoair.wordpress.com/2008/11/07/first-aid-it-for-traveling-abroad/

Caffeine Withdrawal in the Wilderness

coffee-cupCoffee, tea, soda or whatever your favorite ingestion method is…caffeine rocks!  Maybe it is because I am a resident, but I drink tea on a daily basis.  Caffeine helps combat fatigue, increase alertness and the beverages that contain it often taste yummy.  Caffeine is also habit forming and the DSM IVeven lists caffeine as a substance that can cause clinical withdrawal symptoms.

The fact that caffeine can cause clinical withdrawal symptoms and is so widely used has a great impact on those that provide health care to people who may be in a setting where they cannot get their “daily coffee fix”, such as a multi-day wilderness trip or remote travel. Those who are regular coffee drinkers may be familiar with some of the symptoms of caffeine withdrawal:

Headache (gradual onset, often throbbing and severe)

Fatigue

Irritability

These problems usually show up on the second or third day of being “cut-off from their source”.

When people are packing and getting ready for a rafting trip, multi-day hike or any kind of travel that takes them way off the beaten track, hopefully they are putting some planning into their packing and gear. Coffee can be easily forgotten when life-vests, bug spray and potable water are often higher priority items and concerns. This is very wise, but when that severe, throbbing headache creeps up on the second day of your 7 day trip…that caffeine becomes very important.

I speak with a lot of doctors and health care providers that work on expeditions in remote areas and this topic has come up from two physicians I respect, very much. Dr. Howard Donner mentioned, several times at a recent lecture, on problems he faced in treating caffeine withdrawal on multi-day trips. I also had an opportunity to speak with Dr. Sean Hudson about his personal “luxury item” he brings with him on long expeditions and he said, “I always take some good coffee and an MSR filter. I can happily go without food for a day but struggle without my caffeine“. The reason for a lack of caffeine can range from forgetting it, losing it or accidentally having a non-coffee drinker buy the food supplies and buying de-caf (gasp!) or any other method that separates people from their drug of choice.

Fortunately the headaches, typically, respond well to ibuprofen or tylenol and a clever expedition doctor will recognize the symptoms, combine these with the history of no-caffeine for a few days and diagnose a caffeine withdrawal case. Caffeine replacement is also another viable option and there are several forms that can be easily carried by the medical provider. Caffeine tablets are one option, as are premade packets of coffee, with both being very portable and fitting easily in a medical kit.

I feel that is important to state that not all headaches are caused from caffeine withdrawal and a headache could be a sign of a far more serious problem.  However, caffeine withdrawal should be included in the differential diagnosis, especially on the first few days of a trip.

For further reading:
http://www.caffeinedependence.org/caffeine_dependence.html#withdrawal

http://www.medscape.com/viewarticle/490510

Winter Car Travel

As the temperatures start dropping and I am getting ready for the “white stuff” to hit the ground, we are starting to plan out holidays.  Most people I know are looking forward to getting together with their family, whom they may not see too often, and will be driving to the gatherings.

Having a “winter travel car kit” that you can put in the back seat or trunk is important and here are some things that you may want to include, and why:

  • Extra jacket, pants, gloves and hat to keep you warm

Keeping warm, especially if you are having to sit out a blizzard is vital.  Remember that you will be sitting in a car and moving to help generate body heat is vital.  Extra layers can not only add some comfort, but also save a life.

  • Several long burning candles

Candles can help generate heat in the car, provide some light and help you melt snow for drinking water

  •  Matches

Lighters may not work in very cold environments. 

  • Headlamp or flashlight with spare batteries

Unfortunately, you may have to sit out bad weather or wait for help overnight.  A light can do wonders to help signal others, boost morale and assist in finding items in your vehicle.  I am a fan of petzl headlamps.

  • Food such as jerky, hard candy, chocolate, nuts and raisins

Extra calories help you stay warm and a little “comfort food” can go along way

  • A metal cup

Any flame-proof object can be filled with snow and, using your candle, drinking water can be melted.  A metal cup is best because it transfers heat from your candle to the snow inside, faster.  To avoid dehydration, remember to drink before you are thirsty.  All that snow trapping you in your car can at least help you stay hydrated!

  • Mobile phone with charger

Call for help and communicate with others about your position, direction of travel, type/make of car, number of people with you and their condition.  Ideally, a portable battery type charger will keep you from needing to run the car engine and charge your phone.

  • Self-powered radio with weather channels

Get up to date information on road conditions, weather status and something to help pass the time.  The Red Cross has a very nice product that features phone charger, light and several power options.

  • 50 feet of cord

This can be used to tie a “umbilical cord” between you and your vehicle if you have to leave the vehicle.  During a severe “white out” condition, even trying to get from your seat to the trunk and back can be difficult.  Tying a line will allow you to safely reach you vehicle if you have to go outside.  I like to use spectra cord for this purpose.

  • Whistle

Signal for help, alert others to your presence

  • Carbon monoxide detector

There is some danger that keeping your car running helps carbon monoxide build up in the passenger areas, and CO poisoning can kill.  This is not a problem when you are moving, because there is generally adequate ventilation of the inside.  However, a car that is not moving and receiving heavy enough snowfall to block the tail-pipe is at risk for CO poisoning.  Some suggest running your car at intervals (running 5 minutes every 15-20 minutes) to help keep passengers warm.  Still, one should attempt to clear the tail-pipe from snow or debris, allowing better ventilation of the CO gas.  If you do have to leave the car to dig your exhaust pipe out, make sure to use your cord as a tie off around your waist and the vehicle. 

  • Two large plastic garbage bags

Unfortunately, you may need to use the bathroom during your wait and there are about a million uses for garbage bags, including emergency rain jacket

  • Sleeping bag

Help keep everybody warm and cozy

  • Toilet tissue

Can be used as intended, for bathroom breaks, also makes a great fire starter

  • Leatherman multi-tool or swiss knife

Everybody who goes anywhere should carry one of these.

  • Basic first aid kit

An assortment of bandages, pain/fever control such as tylenol, antihistamine, etc.

  • Three days supply of personal medications

If you take medication on a regular basis, you need to have an small supply to last you while you are waiting for the weather to clear and help to arrive.

  • Surveyor’s tape

This can be tied to your antennae, hung out a window or wrapped around anything you want people to notice, especially in bad weather.  Here’s what it looks like and it can be found at most home repair stores.

  • Signal flares

Place these around your care, to help others see your car.  This can help in getting rescuers to see you need help and help other motorists from driving into your stopped vehicle.

There are many web-based resources to learn more about safe car travel, during winter months and especially in bad weather conditions.  Here are a few I liked:

http://www.redcross.org/news/hs/holidaysafety/011217wintertravel.html

http://www.bt.cdc.gov/disasters/winter/guide.asp

http://www.roadandtravel.com/carcare/wintercarpreps.htm

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