I knew there was a good chance I would get sick in going to India. I had all the vaccinations before travelling. I made sure I carried re-hydration mix, extra medication, my injection kit and instructions from the ADSHG website with me.  Once in Delhi I took all the usual precautions to avoid a tummy bug: only eating hot, freshly cooked food; no ice cubes in drinks; drinking only bottled water.

Half way through my assignment, I visited the Taj Mahal on the Saturday.  This was fabulous – truly a wonder of the world –  and well worth the 9 hour round-trip car journey. However, something I ate late on Friday or during my Taj Mahal visit on Saturday started to disagree with me.  Back in my hotel, by the early hours of Sunday morning I was suffering with diarrhoea. On Sunday I did not eat anything, felt progressively worse and then started to feel very cold. I turned off the air conditioning, wrapped up and stayed in bed. I checked the Owner’s Manual and I believe I did everything by the book: I doubled my usual hydrocortisone dose because I had a temperature. I tried to keep hydrated by continually sipping water and I drank some re-hydration mix.

By late evening I realised I was not going to be able to ride this one out. I had a fever of over 99°F (37.2ºC) and I was visiting the bathroom –  my oval office as it had become –  every 10 minutes.  This was not nice. So far that day I had taken a double dose of hydrocortisone three times, making 80mg in total that day. I felt so weak, yet I knew I would be up all night with no chance of sleeping. At 11.30pm I took an extra 20mg hydrocortisone and vomited it up again immediately. This was a bad sign.

I rang the hotel guest services and asked them to call a doctor, since things were getting worse.

I decided I would inject myself with my emergency hydrocortisone (100mg Efcortesol) while the doctor was on his way. I did not know if the doctor would have any knowledge of Addison’s disease or whether he would decide I needed admitting to hospital, which could take some time to arrange. The injection would give me around six hours of cover, which could only be a good thing.

I’m not a fan of needles but I had seen a demonstration the week before at an ADSHG meeting in Guildford and I had the ADSHG step-by-step injection guide at hand. It's not too bad injecting oneself really –  surprisingly like the practice on the orange!

The English-speaking doctor was excellent. I asked a few pertinent questions and he seemed well-informed about Addison's. I had my pills by my bed so it was clear what I was taking. I also had my MedicAlert bracelet. I asked him to take my blood pressure after I stood up as well as lying down, to see if my Addison’s was still reasonably controlled. It was.

The doctor injected me intravenously with an anti-emetic (Domperidome), which stopped the nausea and diarrhoea within about 15 minutes. He prescribed four different anti-nausea and antibiotic drugs to be taken orally. The hotel staff obtained these for me within the hour.

The following day I had total bed rest and some more blood tests. I stayed at double my normal dose for my morning and lunchtime doses and dropped back to normal dose for my early evening one. The doctor was concerned I could have Dengue fever as there had been over 460 cases locally during the two weeks I was in Delhi. He also checked my potassium and sodium, since I am Addisonian. These proved to be exactly mid-range, to the decimal point, in spite of my non-stop bathroom trips. Dengue fever tested negative and the other tests showed I had a standard, gastro-intestinal infection.

The following day I rested, taking my normal 20mg/10mg/10mg doses. I was eating normally and felt I had my strength back. Except that I was nearly 5kg (11lbs) lighter than I had been a few days before!

I regard the whole incident as a positive lesson on managing my Addison’s and preventing a serious illness from developing into a crisis. I have travelled through South America and South East Asia in the past without any tummy troubles, and had actually left it until the last minute before my Delhi trip to get an up-to-date injection kit. If I had not know how to handle fever, diarrhoea and vomiting, had not got my new injection kit or been confident in how to use it on my own, things may not have turned out the same. I am glad it all ended happily.

Gavin

November 2003

Delhi Belly - The doctor's view

Gavin did everything right and by the book: he was well prepared; he took his emergency injection after progression of the gastric illness and his first episode of vomiting; he sought a doctor’s advice early in case the situation deteriorated or hospitalisation and IV fluids were needed.

Gavin’s increased doses and his tapering were spot on. Despite diarrhoea, fluids and medication can still be absorbed in the stomach and small bowel though in reduced amounts.

If, unlike Gavin, a traveller is away from the relative comforts of bed-rest, a hotel and access to a well-informed doctor, then a more aggressive self-medication policy might be needed. In such situations, such as hiking/tramping in backcountry, a longer acting oral preparation such as dexamethasone 2-4 mg may be helpful to take in the self-help medical kit. 

Dexamethasone lasts for up to 36 hours; it comes in 4 mg tablets that are equivalent to about 80 mg hydrocortisone. If using dexamethasone, take regular fludrocortisone and rehydration fluids as well as at least two vials of hydrocortisone for injection backup. A plan of retreat –  with a companion –  is needed in case the gastric illness progresses over 12 - 24 hours, especially if there is dizziness or vomiting.

But with early and adequate steroid cover, there is no reason why the gastric illness and recovery phase for an Addisonian should be any different from that experienced by their equally miserable non-Addisonian companion with Delhi belly or Montezuma’s revenge!    

Traveller’s diarrhoea, with or without vomiting and fever, typically lasts for 3 - 5 days.  It can occur despite all or any precautions, useful though they are. While there are many causes of diarrhoea, the commonest is an infection with local strains of E Coli bacteria. Treatment depends on the severity and progression of the illness.

It is reasonable for travellers to carry an anti-motility agent (such as loperamide) plus an antibiotic (such as norfloxacin or ciprofloxacin), with specific advice on how and when to use them. These drugs will shorten but not prevent an illness such as Gavin’s. 

I hope that Gavin’s response to treatment for any future traveller’s tummy will be as rapid a recovery as this one!

You may also be interested to read: BMJ 314; 1776, 1997….”Treating diarrhoea”

Mike Croxson

Consultant Endocrinologist

Auckland, New Zealand