By Peter Mouldey, M.D.
Each year I try to take a trip to a dive location in Central or South America which is off the beaten path. The more difficult the place is to access and the fewer people who have gone there, the more I am interested in exploring the site. Usually this involves small airplane, boat, or overland rides which the average diver just would not do. And with this kind of trip, the risk of a tropical disease increases as one spends more time in rural areas with fewer tourist services. But it is this adventure both above and below the water that keeps me sane (or so I think) in what is otherwise quite a stressful job environment.
Given the recent dengue epidemics this past winter in Hawaii, Cuba and Brazil -- all places frequented by divers -- the two recent thorough articles on dengue fever in Alert Diver (July and August 2002) were topical and timely.
Despite taking the necessary precautions, such as using DEET* to minimize mosquito bites, I contracted dengue fever this past November while snorkeling in the Caribbean. My fever began as I arrived in Toronto and worsened over the next day. The worst part of the seven-day illness was the headache, severe fatigue and muscle aches.
On the second day of the illness, I developed a rash head to toe; it looked like a scarlet fever rash, confluent, flat and blanched, very characteristic in early dengue fever. At that point, I went to the local emergency department and told the physician I thought I might have dengue because of the fever, headache, joint pain and rash.
To my astonishment, the emergency room physician said dengue fever did not exist in that part of the Caribbean. He attributed the rash to sunburn, despite the fact I had not removed my shirt while in the tropics except to swim. When he refused to do the blood test for dengue, I left and decided to go to a hospital that had a tropical disease clinic.
Because of the rash, I got to see the junior resident, the infectious disease fellow and a staff physician at the second hospital. They all agreed this was likely dengue, but they also wanted to rule out malaria and leptospirosis.
The diagnosis was classical dengue fever, serotype 3 of which my acute symptoms resolved after a week. The worst part of the illness turned out to be the post-viral fatigue. The DAN article only alludes to this common and debilitating complication, which has also been described as depression or profound exhaustion.
My fatigue was profound and lasted close to eight weeks. This pattern is similar to the fatigue pattern seen in infectious mononucleosis. What actually causes it is not known; however, it does respond to rest and proper diet, followed after a few weeks with a gradual program of aerobic exercise.
My message to other divers and travelers is this: If you think you have dengue, malaria or any tropical disease, go to a hospital which has a physician who knows something about these diseases.
Most travelers have read up on the diseases they might be exposed to in the areas they will be visiting, or have been to travel clinics beforehand to reinforce this knowledge. While travelling, they may have heard about the local disease patterns. This often makes the traveler far more informed than the ER doctor in their home city.
If you think you might have dengue fever or malaria, don't leave the ER until a doctors orders a blood test: that will rule out these diseases. If you are still not satisfied, seek out another hospital.
Divers and travelers in general should remember that while the risk of disease from traveling in the tropics is real, the risk of dying from an infectious disease acquired in the tropics is very low. In fact, the most common cause of death among traveling divers is not infectious, but from motor vehicle accidents. So in addition to spraying yourself with DEET, assess the taxi driver's skills and the vehicle's condition, put on a seatbelt, and, whenever possible, avoid vehicular travel at night.
*(DEET -- chemical name N,N-diethyl-meta-toluamide), a colorless oily liquid insect repellent developed in the early 1960s.
About the Author:
Dr. Peter Mouldey received his medical degree from University of Toronto in 1990. He is a family doctor in Toronto, with an interest in dive and travel medicine. "I have been a DAN member since 1997, and, as with my credit card, I don't leave home without my DAN card," Mouldey said. "I attended the 46th Diving and Hyperbaric Medicine course put on by DAN last summer and would say it was the best CME I have attended in a long time." Last summer he completed his PADI Advanced Open Water certification.
From the January / February 2003 issue of Alert Diver.