Tropical fevers: Management guidelines

Abstract

Tropical fevers were defined as infections that are prevalent in, or are unique to tropical and subtropical regions. Some of these occur throughout the year and some especially in rainy and post-rainy season. Concerned about high prevalence and morbidity and mortality caused by these infections, and overlapping clinical presentations, difficulties in arriving at specific diagnoses and need for early empiric treatment, Indian Society of Critical Care Medicine (ISCCM) constituted an expert committee to develop a consensus statement and guidelines for management of these diseases in the emergency and critical care. The committee decided to focus on most common infections on the basis of available epidemiologic data from India and overall experience of the group. These included dengue hemorrhagic fever, rickettsial infections/scrub typhus, malaria (usually falciparum), typhoid, and leptospira bacterial sepsis and common viral infections like influenza. The committee recommends a ‘syndromic approach’ to diagnosis and treatment of critical tropical infections and has identified five major clinical syndromes: undifferentiated fever, fever with rash / thrombocytopenia, fever with acute respiratory distress syndrome (ARDS), fever with encephalopathy and fever with multi organ dysfunction syndrome. Evidence based algorithms are presented to guide critical care specialists to choose reliable rapid diagnostic modalities and early empiric therapy based on clinical syndromes.

Assessment and initial management of acute undifferentiated fever in tropical and subtropical regions

“…Empirical therapy with a combination of parenteral third generation cephalosporin (ceftriaxone) along with doxycycline or azithromycin is appropriate while diagnostic confirmation is awaited 8687. Ceftriaxone provides coverage for enteric fever, and leptospirosis; while doxycycline provides coverage for rickettsial infections.…”

“…Ceftriaxone provides coverage for enteric fever, and leptospirosis; while doxycycline provides coverage for rickettsial infections. This combination is also appropriate for AUFIs complicated by pneumonia or acute respiratory distress syndrome, encephalopathy, and liver involvement87 and does not require dose modification in renal failure7988 and multi-organ failure. Finally, this combination may also be administered to patients suspected of, or diagnosed with, severe malaria, in addition to intravenous artesunate.…”

Fiebre, ictericia y hepatitis: no siempre es infección viral

“…Se encuentra aproximadamente en el 12,2% de los pacientes (3), en general se produce al inicio de los síntomas, durante la primera semana del cuadro febril, y se resuelve con el cuadro clínico, a diferencia de la hepatitis viral, en la cual la fiebre desaparece cuando sobreviene la ictericia, o en otras palabras, con la ictericia desaparecen los síntomas prodrómicos (2,13,18,19). La hepatomegalia se encuentra en todos los pacientes con hepatitis por Salmonella (18)(19)(20), así como pueden cursar con esplenomegalia; estas visceromegalias pueden ser evidentes en el examen físico o por ecografía abdominal (20).…”

“…Se encuentra aproximadamente en el 12,2% de los pacientes (3), en general se produce al inicio de los síntomas, durante la primera semana del cuadro febril, y se resuelve con el cuadro clínico, a diferencia de la hepatitis viral, en la cual la fiebre desaparece cuando sobreviene la ictericia, o en otras palabras, con la ictericia desaparecen los síntomas prodrómicos (2,13,18,19). La hepatomegalia se encuentra en todos los pacientes con hepatitis por Salmonella (18)(19)(20), así como pueden cursar con esplenomegalia; estas visceromegalias pueden ser evidentes en el examen físico o por ecografía abdominal (20). Además de las manifestaciones sistémicas que pueden apoyar el diagnóstico como miocarditis, insuficiencia renal, y alteraciones hemorrágicas y cutáneas (como la presencia de exantema [30%]) (7,9,15,17), también es frecuente encontrar bradicardia, a pesar de la fiebre, y esta situación es una característica clásica de la entidad (1, 2, 4, 7).…”

\"Syndromic approach\" to diagnosis and treatment of critical tropical infections

“…[1] According to this publication, a syndromic approach covering “five major clinical syndromes: Undifferentiated fever, fever with rash/thrombocytopenia, fever with acute respiratory distress syndrome, fever with encephalopathy, and fever with multi-organ dysfunction syndrome” was mentioned. [1] The syndromic approach seems to be a useful approach; however, there are some concerns about it. The approach might cover many infections; however, it can underestimate several other conditions.…”