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Heart Valve Infection Masquerading as Angolan Typhoid Fever

International Medicine Center is most often contacted because of concern about possible infection with a tropical disease agent. Often, it doesn’t work out that way.

Wednesday, May 9, 2012, we received a call from the elderly father of 46yr-old John. His voice was urgent on the need for an appointment on Thursday for his son, en route to the U.S. from Angola, Africa. John was deathly ill, having had fever of unknown cause since April 26th. He had been treated in a clinic in Angola with intravenous antibiotics, with no medical tests revealing a cause for his illness. The European physician attending him told John it was critical to get to medical expertise that might help him, and so he must leave Angola. Time was running out.

John contacted his dad in his hometown, Little Rock, Arkansas. He told him to start the process of locating the right doctor. Meanwhile, John made the arduous connecting flights from Cameroon to Europe, and then to the U.S. Throughout he had fever, hard chills, and severe pain – especially in his head, chest, left ankle and thigh, left triceps muscle, and right arm. His ankle had become swollen and he could hardly bear weight on it.

John’s father did what most of us would. He called the family physician they had relied on for decades. As he heard the frightening story and the unusual location of illness onset, Africa, their personal physician knew that the situation needed incisive diagnostic and treatment action that would not tolerate inexperienced decision-making. He particularly understood that the vast majority of U.S.-based physicians would not have any familiarity with esoteric tropical diseases that were some of the possibilities: typhoid fever, malaria, dengue fever. The family doc advised that John not come home. Little Rock did not have the required expertise. He should stop short, and stay in Dallas or Houston, TX.

John’s dad went to work on the Internet. In his search for exotic disease expertise, he settled on the International Medicine Center (IMC) and Dr. Edward Rensimer. A quick phone call followed.

As soon as the request was put before Dr. Rensimer, he asked for an ETA. It would be early afternoon Thursday when the flight should touch down. By the time they would arrive at the office, it would be approaching office closing time. However, Dr. Rensimer, aware of the ominous prospects, told his staff to have them come ASAP and we would see them.

Upon entering the exam room, Dr. Rensimer found a hunched over, pale, dehydrated man, usually athletic, now frail and bundled in clothing to subdue the violent shakes. His concerned father, far from their home and now turning his critically ill son over to strangers, sat quietly and worried.

After thoroughly questioning John, Dr. Rensimer carefully examined him. When did those dark spots appear on several finger tips of both hands? Did you know you have a heart murmur? Had you even been told you had a heart murmur? Dr. Rensimer reviewed the records from Cameroon. He then turned to John and his dad. “You must be hospitalized immediately. Though malaria and other diseases specific to Africa must be screened for, I believe you have bacterial infection of your heart valves [endocarditis], and that you are throwing infected blood clots to various parts of your body, causing the severe areas of pain, swelling, and discoloration. If I am right, this is a life-critical diagnosis. There is no time to lose.”

John went straightway to the nearby acute care hospital where Dr. Rensimer is on the attending medical staff. Dr. Rensimer went by that evening to assure John was stable and that things were in motion. In the days ahead, cultures of John’s blood were growing the Staphylococcus aureus bacterium. Within 24 hours of admission, an emergency transesophageal echocardiogram performed by a cardiologist revealed a very dysfunctional “leaky” heart valve with bacterial vegetations on it. The valve was being destroyed rapidly by infection. Dr. Rensimer’s initial suspicion was verified and the patient was started on appropriate IV antibiotics. Subsequent studies showed John had showered his organs, two to his brain, with blood clots originating on the infected valve. It was miraculous that John had not died on the flights home or ultimately suffered any major organ damage. Unchecked, sudden, cataclysmic value rupture could lead to fulminant, intractable congestive heart failure and death.

John was stabilized over several days in the Critical Care Unit. Eventually, with a team of expert medical and surgical specialists assembled by Dr. Rensimer, the destroyed, infected heart valve was successfully removed and a prosthetic valve was placed. John completed his medical treatment. After a short stay in Little Rock, he returned to his full-time career in Cameroon without restrictions. 8 months after his harrowing journey to the U.S., he returned to Houston and was judged to be infection free and with a normally functioning heart.

Conclusion: At IMC, daily we are referred the extraordinary, the unorthodox, and the exotic/esoteric. The tropical medicine prospects posed by John’s case certainly qualified. However, just as U.S. trained and experienced doctors might “miss” such possibilities, IMC must always also consider more usual, but no-less ominous, afflictions. Staphylococcal endocarditis is an extremely uncommon, almost rare, disease anywhere and delay in diagnosis and initiation of proper treatment can be fatal. It is noteworthy that, despite the curve-ball of tropical disease considerations, the correct, critical diagnosis was made on clinical grounds (no testing) within 30 minutes of first contact in a patient with nothing by history to suggest he should have been at risk for endocarditis.

Critical decision-making; real-time rapid, appropriate triage; targeted, appropriate testing and treatment; team assembly of the best specialists for the situation; and unsurpassed diagnostic expertise is what we do at IMC. We cut through the medical bureaucracy to get the job done.

International Travel Tips

Over-the-Counter Medications and Supplies:

  • Antacid
  • Antibacterial handwash
  • Anti-constipation (Dulcolax)
  • Anti-diarrheal (Imodium AD or Pepto-Bismol)
  • Anti-fungal (Monostat)-female travelers
  • Antihistamine (Benadryl)
  • Anti-inflammatory (ibuprofen)
  • Aspirin or other analgesic (pain-killer)
  • Bandages and antibiotic ointment
  • Cold tablets
  • Decongestant (Sudafed)
  • Hydrocortisone cream 0.5% t0 1%
  • Thermometer

Prescription Medications:

  • Sufficient supply of all your usual medications for a week beyond the duration of your trip, including antibiotics, oral contraceptives, etc. (leave a list of medications taken on your trip at home, preferably on an Internet-accessible computer)

Medical Alert Bracelet or Wallet Card:

  • For allergies, or a serious health condition

Other Considerations:

  • Waterproof Sunscreen with SPF 15 or higher
  • Insect repellant with 20% DEET
  • Extra pair of glasses or contact lenses

Special Medical Supplies:

  • Syringes for diabetics
  • Epinephrine (EpiPen) for serious allergy problems
  • Syrup of Ipecac if traveling with children (induce vomiting, if poisoned)

“TO DRINK OR NOT TO DRINK”

Unsafe Beverages:

  • Water or ice from hotel sinks, restaurants, and public restrooms
  • Unprocessed or chemically untreated water
  • Beverages from glasses with moisture on them
  • Carbonated drinks that are served with ice
  • Bottled water without a manufacturer’s seal
  • Raw milk

Do not use tap water to brush your teeth!

Safe Beverages:

  • Boiled or otherwise purified water
  • Internationally known brands of bottled water or carbonated drinks (without ice)

“TO EAT OR NOT TO EAT”

Unsafe Foods:

  • Foods that are not fully cooked
  • Foods prepared far in advance of eating
  • Foods made with eggs, mayonnaise, chicken, creams, or custards
  • Raw or partially cooked meats, fish, or shellfish
  • Foods served on dinnerware that is wet from washing
  • Fresh fruits and vegetables with broken skins or that you cannot peel yourself
  • Foods purchased from street vendors

Safe Foods:

  • Thoroughly cooked foods that are served hot
  • Fresh fruits or vegetables with intact skins
  • Foods that are packaged or canned
  • Rice, beans, or grains that are freshly cooked
  • Bread and other baked goods 

Getting Around Safely

Motor vehicle accidents are the leading cause of death of travelers to developing countries. Travelers involved in these accidents are also at risk for contracting serious illnesses through foreign medical system blood transfusions and injections (AIDS, hepatitis B/C).

  • Avoid overcrowded public vehicles.
  • Do not drive after dark (especially in rural areas).
  • Do not drive motorcycles (14 times more risky per mile traveled).
  • Wear a seatbelt.

Fresh Water

Slow-moving fresh water rivers, lakes, and streams in many developing countries should be enjoyed from a safe distance. It is common for these waters to be infested with parasites that are capable of penetrating the unbroken skin and causing serious illness.

If contact is unavoidable, towel dry vigorously  to reduce the risk of a parasite entering the skin, especially the feet.

High Altitude

Altitude sickness can have serious consequences and can even be fatal.

  • Make your ascent gradually, allowing time for adaptation on the way up.
  • Drink plenty of fluids.
  • Avoid overexertion (out of proportion to your physical condition and fitness level).
  • Avoid sedatives, aspirin, codeine, and alcohol.
  • Consider using acetazolamide (Diamox) preventively.

Asian Travel: Carry TamiFlu?

May 2006

Tamiflu (oseltamivir phosphate) is effective against most strains of influenza virus A and B.  This includes the Asian avian influenza (AAI), Type A H5N1 strain. This virus has been confirmed to have infected a number of people, with a substantial risk of death. Many were young, healthy individuals (as with the 1918 Spanish influenza pandemic).

Tamiflu can speed recovery by 1-2 days, and markedly reduces serious flu complications, such as secondary bacterial pneumonia.

To be effective Tamiflu must be taken within 48 hours of first symptoms: abrupt, high fever; cough/congestion; severe muscle aches; headache. There is no human vaccine available for the H5N1 strain, although work on a potential vaccine is ongoing.

So far, most of the AAI flu cases occurred by direct contact with infected poultry – chickens or ducks – or environmental surfaces contaminated by their feces/excretions. But, the concern that the bird Type A H5N1 strain could genetically mingle with more traditional human flu viruses, allowing it to become a lethal human flu strain, spreading human-to-human, is real; so real that countries have placed orders to stockpile millions of doses of Tamiflu. The Infectious Diseases Society of America has recommended that the U.S. stock 150 million doses.

The concern is for an influenza pandemic – multiple, concurrent continental epidemics worldwide. The 1918 Spanish influenza pandemic caused 25 million deaths in 6 months. The pre-condition for that pandemic as well as the one predicted to occur soon in the upcoming years (by the Asian A H5N1 strain or other flu virus) is an immunologically novel influenza virus for humans, with no immunity experience from prior illness with the specific flu virus strain or closely related prior flu virus strains or from influenza vaccines used in prior years. In other words, with an epidemic from a viral strain to which people are immunologically naked, 2.2 million deaths in the U.S. are predicted. Worldwide the toll would be unimaginable.

Although the Centers for Disease Control (CDC) has not yet issued a travel advisory for the general public, these facts should at least prompt consideration for carrying a supply (5 day treatment course) of Tamiflu by individuals traveling or residing in countries where  human or bird cases have occurred (and possibly contiguous nations, as well):

 

Animal Cases
Since December 2003, avian influenza A (H5N1) infections in poultry or wild birds have been reported in the following countries:
Africa: Europe & Eurasia:
Burkina Faso Albania
Cameroon Austria
Cote D’Ivoire Azerbaijan*
Djibouti* Bosnia & Herzegovina (H5)
Egypt* Bulgaria
Niger Croatia
Nigeria Cyprus
Sudan Czech Republic
East Asia & The Pacific: Denmark
Cambodia** France (H5)
China* Germany
Georgia Greece
Hong Kong (SARPRC) Hungary
Indonesia* Italy
Japan Poland
Laos Romania
Malaysia Russia
Mongolia Serbia & Montenegro
Thailand** Slovakia
Vietnam** Slovenia (H5)
Near East: Sweden
Afghanistan Switzerland
Egypt Turkey*
Iran Ukraine
Iraq (H5)* United Kingdom
Israel
Jordan
Pakistan
South Asia:
Burma (Myanmar)
India
Kazakhstan
*human cases
**most cases human
For additional information about these reports, visit theWorld Organization for Animal Health Web site.Updated May 30, 2006

Availability of the drug locally cannot be relied upon and it must be started immediately upon becoming ill or after credible exposure (as an illness preventive strategy). Older flu drugs, amantidine and rimantidine, are not effective against this strain. Relenza (zanamivir) is effective, but cannot be used in those less than 12 years old or in those with respiratory disease (asthma, COPD, etc.).

Officials at the CDC and the World Health Organization (WHO) believe that the H5N1 Type A strain has become endemic to the birds in the affected regions and that human infections will continue. They feel it is possible this strain will evolve into a deadly human pathogen (once there is human-to-human transmission possible).

Asian Avian Flu Preparations

  • Regional Destination Disease Activity Information: update yourself: http://www.cdc.gov/flu/avian/index.htm
  • Asian Avian Flu Kit:
    • thermometer
    • alcohol-based hand rub for hand hygiene
    • Tamiflu 75mg twice daily x 5 days
    • In-Country Healthcare Resources: identify pre-travel
    • Medical Evacuation Health Insurance
  • During Travel
    • Avoid direct contact with poultry/fowl – live or dead.
    • Avoid poultry farms and bird markets.
    • Avoid handling surfaces contaminated with poultry feces/excretions.
    • Perform careful, frequent hand cleansing.
    • Thoroughly cook all poultry products – heat kills flu virus.
    • If you become sick abroad, contact U.S. consulate to locate medical services.
  • After Travel
    • If you become ill within 10 days of return, immediately notify your physician or a travel medicine/infectious diseases specialist, emphasizing the specifics of your recent travel.

 

Edward R. Rensimer, MD, FACP

Director, IMC

Chagas Disease: Unspoken Threat in the Americas

Last Updated: March, 2012

Chaga’s disease (American trypanosomiasis) is a parasitic infection transmitted to humans by reduvid bug defecation into broken skin or conjunctival mucous membranes (pink inner lining of eyelids) while taking a blood meal, typically at night. The parasite, Trypanosoma cruzi, exists in the far south of the United States, Central America, and throughout South America down to central Argentina and Chile. It is the 3rd most important worldwide tropical disease, after malaria and schistosomiasis.

Epidemiology

Transmission also occurs by infected transfused blood units, usually in cities with symptom-free, infected immigrant blood donors.

1)    Infected insects found in:

  • burrows
  • hollow trees
  • palm trees
  • niches in primitive wood, mud/adobe, and stone houses (i.e. substandard construction rural dwellings), especially with thatched roofs

2)   Central/South America:

  • Approximately 18 million infected: highest concentration of cases = southern Mexico to Northern Argentina and Chile (Amazon basin and Caribbean are exceptions)
  • 45,000 deaths/year
  • Blood supply high-risk: in Bolivia, 1960-89, 53% blood donors seropositive for T. cruzi

3)   United States:

  • In recent decades, with increasing immigrants from C/S. America, chronic T. cruzi infection has grown considerably; many are from Central America where prevalence of Chaga’s is high.
  • Estimate: 80,000 – 100,000 infected in U.S.
  • Raises concern over risk of blood supply and organ transplants

Note: There have been locally acquired parasite cases in Texas and California

Disease States

1)  Acute Disease* (fatality rate = 10%): In 7-10 days,

  • swollen, firm skin lesion (chagoma) at point of parasite entry with swollen, local lymph nodes; or painless, swollen eyelids on one side of face
  • fever, poor appetite, malaise
  • edema of face and legs
  • generalized swollen glands and enlarged liver/spleen

* Most cases are initially asymptomatic or only mildly ill.

2) Indeterminate Phase: majority of cases go to this after the acute phase – no symptoms, low-grade parasite levels in blood, positive T. cruzi antibody blood test.

3) Chronic Disease (years – decades after initial infection):

  • Inflamed, enlarged (right) heart: heart failure, arrhythmias, thromboemboli (blood clots)
  • Enlarged esophagus: difficult, painful swallowing; regurgitation; chest pain
  • Megacolon: enlarged colon with chronic constipation and abdominal pain
  • 10-30% of those with chronic T. cruzi infection are symptomatically ill.
  • Central nervous system infection

Treatment

Nifurtimox and benznidazole are drugs with parasite cure rate of 70%; duration of treatment is 60-120 days. These drugs have significant intolerances/toxicity.

Prevention

  1. No vaccine or chemoprophylaxis (preventive meds) available
  2. Travelers:
    1. Avoid sleeping in dilapidated dwellings, particularly with cracks, crevices in walls.
      1. Search sleeping areas thoroughly for reduvid bugs.
      2. Avoid overnight stays in endemic, rural areas.
      3. Consider sleeping outdoors.
    2. Insect repellent
    3. Bed nets indoors and outdoors
    4. Absolutely receive no blood transfusions in Chaga’s endemic areas, unless a life-threatening emergency exists.

 

Edward R. Rensimer, MD, FACP

Director

Coach Class/Economy Class Syndome

February 10, 2012

It is widely accepted that deep vein thrombosis (blood clot formation) or DVT in the legs is a risk of long-distance (greater than 5,000 miles) travel. The combination of immobility, dehydration, and seat pressure on veins at or below the knees increase the risk of blood clot formation. DVT is undiagnosed in 80% of cases. DVT may result in movement of the clot to the lungs (embolism) which accounts for 1 in 20 deaths in those older than 50. The incidence of DVT in the general (not hospitalized) population is unknown, but may be significant.

Risk factors for such clotting:

  • Prior history of DVT/pulmonary embolism (PE)
  • Obesity (>20% above ideal body weight)
  • Varicose veins
  • Recent surgery (with anesthesia) or physical trauma
  • Autoimmune disease
  • Type A blood type
  • Cancer/Chemotherapy
  • Clotting disorders (increased coagulability)
  • Congestive heart failure
  • Hyperlipidemia (elevated cholesterol)
  • Inflammatory bowel disease (Crohn’s/ulcerative colitis)
  • OB/GYN: Oral estrogens, Pregnancy/Post-Partum Period
  • Polycythemia/Elevated platelet counts
  • Limited mobility
  • Advanced Age

Although there are not sufficient data to routinely recommend preventive blood-thinning medications for air travel, graduated compression stockings have been shown to significantly reduce the chance of DVT in those with risk factors for excessive blood clotting.

Other highly advised recommendations:

  1. Attention to activity during the flight. Any activity that periodically (at least hourly) contracts the leg muscles (especially calves) is beneficial in keeping blood moving.
  2. Avoid dehydration by avoiding caffeine and alcohol, and by drinking liquids each hour.
  3. Consider routinely wearing gradual compression stockings (usually 15-30mm Hg pressure) for all lengthy (over 8 hours or 5,000 miles) plane flights and car trips.

IMC stocks top-quality, medical-grade stockings (ask our staff to show them).

Edward R. Rensimer, MD, FACP
Director, IMC