Fever in the Returning Traveler

Aka: Fever in the Returning Traveler, Febrile Ilness in Recent Travelers, History from the Ill Returning Traveler, Fever in Returned Travelers

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II. Indications

  1. Recent travel in the last 3-4 weeks

III. Risk Factors

  1. Longer trips
  2. Lack of Pretravel Consultation (esp. lack of travel Vaccination, Malaria Chemoprophylaxis)
  3. Underlying comorbidity
  4. Pregnant women and children
  5. Travel to rural regions
  6. Outdoor activities (e.g. hiking, water activities)

IV. Precautions: Malaria risk

  1. Fever in a returning traveler from Malaria endemic area is Falciparum Malaria until proven otherwise
    1. Stat blood smear with direct communication with reading pathologist
    2. Especially consider Malaria with Leukopenia and Left Shift, Thrombocytopenia
    3. Up to 50% of Malaria cases are misdiagnosed on the first visit
    4. Initial presentations are often mild and non-specific (fever, chills, malaise, myalgia, Headache)
    5. This is an emergent evaluation
  2. Other common causes in the differential of Malaria
    1. Viral Hepatitis
    2. Typhoid Fever
    3. Dengue Fever
    4. Chikungunya
    5. Zika Virus
  3. Other important travel-related infectious disease to consider
    1. Leptospirosis
    2. Typhoid Fever
    3. Trypanosomiasis
    4. Schistosomiasis
  4. Consider Bacterial infectious conditions unrelated to travel
    1. Pneumonia
    2. Urinary Tract Infection
    3. Meningitis

V. Causes: Fever with other organ involvement

  1. See Cutaneous Conditions in Febrile Returning Traveler
  2. See GI Conditions in Febrile Returning Traveler
  3. See Altered Mental Status in Febrile Returning Traveler
  4. See Lymphadenopathy in the Febrile Returning Traveler

VI. Causes: By frequency in febrile travelers returning to developed countries

  1. Malaria (21%)
  2. Febrile Diarrhea (15%)
  3. Febrile respiratory infections (14%)
  4. Dengue Fever (6%)
  5. Non-Diarrheal, febrile gastrointestinal illness (5%)
  6. Fever with rash (4%)
  7. Genitourinary infections with fever (4%)
  8. Ricckettsia (2%)
  9. Typhoid Fever or Paratyphoid Fever (2%)
  10. Wilson (2007) Clin Infect Dis 44(12): 1560-8 [PubMed]

VII. Causes: Geographic regions

  1. Caribbean
    1. Malaria (Haiti)
    2. Dengue Fever
    3. Zika Virus
    4. Also consider acute Histoplasmosis, Leptospirosis
  2. Central America and South America
    1. Malaria (primarily Plasmodium Vivax)
    2. Dengue Fever
    3. Yellow Fever
    4. Enteric Fever
    5. Zika Virus
    6. Also consider Leptospirosis, Leishmaniasis, Chagas Disease, Histoplasmosis, Coccidioidomycosis, Bartonellosis
  3. South Central Asia
    1. Malaria (typically NOT Plasmodium Falciparum)
    2. Dengue Fever
    3. Enteric Fever (Salmonella typhi and paratyphi)
    4. Severe Acute Respiratory Syndrome (SARS)
    5. Also consider Chikungunya virus
  4. Southeast Asia
    1. Malaria (typically NOT Plasmodium Falciparum)
    2. Dengue Fever
    3. Severe Acute Respiratory Syndrome (SARS)
    4. Enteric Fever
    5. Also consider Chikungunya virus, Leptospirosis, Japanese Encephalitis, Leishmaniasis
  5. Sub-Saharan Africa
    1. Malaria (mostly Plasmodium Falciparum)
    2. Tick-borne Rickettsiae
    3. Acute Schistosomiasis
    4. Filariasis
    5. Yellow Fever
    6. Leishmaniasis
    7. Also consider hemorrhagic fever, african trypanosomiasis
  6. West Africa (Liberia, Sierra Leone, Guinea)
    1. Ebola (as of 2014)
  7. Worldwide conditions
    1. Human Immundeficiency Virus (HIV)
    2. Hepatitis A (common) , Hepatitis E, and other Viral Hepatitis
    3. Malaria
    4. Tuberculosis
  8. References
    1. See CDC Yellow Book resource below

VIII. Causes: Exposure Related Febrile Illnesses

  1. Sexually Transmitted Disease
    1. Gonorrhea
    2. Human Immunodeficiency Virus (HIV)
    3. Syphilis
    4. Hepatitis B Virus
    5. Chancroid
    6. Herpes Simplex Virus
  2. Vector Contact
    1. See Vector Borne Disease
    2. Mosquitoes
      1. Malaria
      2. Dengue Fever
      3. Yellow Fever
      4. Chikungunya
    3. Ticks
      1. Rickettsioses
      2. Tularemia
    4. Reduviid Bugs
      1. American Trypanosomiasis
    5. Tsetse Flies
      1. African Trypanosomiasis
  3. Animal Contact
    1. See Pet-Borne Parasitic Zoonoses
    2. Rabies
    3. Q Fever
    4. Tularemia
    5. Brucellosis
    6. Echinococcosis
    7. Plague
    8. Psittacosis (Bird exposure)
  4. Infected Person Contact
    1. Viral Hemorrhagic Fever
    2. Enteric Fever (Salmonella typhi and paratyphi)
    3. Meningococcal infection
    4. Tuberculosis
    5. Severe Acute Respiratory Syndrome
  5. Raw or undercooked meat or fish
    1. See Foodborne Illness
    2. Enteric Infections
    3. Cestodiasis
    4. Trichinosis
    5. Typhoid Fever
    6. Cholera
    7. Salmonellosis
  6. Untreated water or unpasteurized dairy products
    1. See Waterborne Illness
    2. Salmonellosis
    3. Shigellosis
    4. Hepatitis A
    5. Amebiasis
    6. Cholera
    7. Brucellosis (dairy exposure)
    8. Tuberculosis (dairy exposure)
  7. Freshwater Exposure
    1. Acute Schistosomiasis (Katayama Fever)
    2. Leptospirosis
    3. Campylobacter
  8. Barefoot Exposure
    1. Strongyloidiasis
    2. Cutaneous Larva Migrans
  9. Infected soil exposure or cave exploring
    1. Histoplasmosis
    2. Rabies
    3. Marburg Hemorrhagic Fever
    4. Leptospirosis
    5. Tick-Borne Relapsing Fever
    6. Tetanus

IX. Causes: Incubation Periods

  1. Incubation <7-10 days
    1. Traveler's Diarrhea
    2. Dengue Fever (common)
    3. Yellow Fever
    4. Spotted Fever (Rickettsiae)
    5. Meningococcemia
    6. Chikungunya
    7. Zika Virus
    8. Severe Acute Respiratory Syndrome (SARS)
  2. Incubation 7-21 days
    1. Leptospirosis
    2. Viral Hemorrhagic Fevers (including Ebola)
    3. Japanese Encephalitis
    4. Malaria (common)
    5. Enteric Fevers
      1. Typhoid Fever (common)
      2. Paratyphoid
    6. Typhus
    7. East African Trypanosomiasis
    8. Q Fever
  3. Incubation >21 days
    1. Human Immundeficiency Virus (HIV)
    2. Hepatitis A (common) , Hepatitis E, and other Viral Hepatitis
    3. Malaria (common, symptoms may be delayed months)
    4. Tuberculosis (common, symptoms may be delayed years)
    5. Amebic Liver Abscess
    6. West African Trypanosomiasis
    7. Borreliosis
    8. Brucellosis
    9. Visceral Leishmaniasis
    10. Systemic Schistosomiasis (Katayama)
  4. Months
    1. Chagas Disease
    2. Tuberculosis

X. History

  1. Travel itinerary (establish a travel and exposure timeline)
    1. Who did you see (family, wildlife, farm animals)?
    2. Where did you travel (what country, what environments, what living conditions)?
    3. When did you travel and for how long?
    4. What did you do (wilderness travel, mission work, farm work, construction)?
    5. Did you seek medical care while traveling?
  2. Exposures
    1. Insects (e.g. ticks, Mosquitos)
      1. See Vector Borne Disease
    2. Animal exposures (including farm animals)
      1. See Pet-Borne Infection
      2. See Animal Bite
      3. See Marine Injury
    3. Skin Trauma
      1. See Cellulitis for specific exposures
    4. Contagious contacts (in travel country or home country)
    5. Sexually Transmitted Infection risk or exposure while traveling
    6. Food sources of infection
      1. See Foodborne Illness
    7. Water sources of infection (ingestion, fresh water swimming)
      1. See Waterborne Illness
  3. Medications
    1. New medications (especially immune compromising medications)
    2. Medications purchased in local pharmacies while traveling
    3. Pretravel Immunizations (and other Immunization status)
    4. Pretravel antibiotic prophylaxis (e.g. Mefloquine for Malaria Prophylaxis)
      1. Even with compliant use of prophylaxis, Malaria may still occur

XI. Symptoms

  1. Fever pattern and course
    1. See Fever
  2. Cough
    1. Often due to common Upper Respiratory Infections
    2. Influenza or Pneumonia (Close contact with local population)
    3. Q Fever (Farm exposure)
    4. Legionellosis
    5. Leptospirosis
    6. Acute Schistosomiasis or Katayama Fever (boating or swimming in sub-saharan africa or southeast asia)
    7. Coronavirus
      1. Severe Acute Respiratory Syndrome (SARS)
      2. Middle East Respiratory Syndrome (MERS)
  3. Gastrointestinal symptoms
    1. See Gastrointestinal Disease in Returning Traveler
    2. Abdominal Pain
    3. Diarrhea
      1. See Traveler's Diarrhea
  4. Rash
    1. See Febrile Traveler with Rash
    2. Dengue Fever
    3. Chikungunya
    4. Zika Virus
    5. Typhus
    6. Enteric Fever
    7. Meningococcus
    8. Uncommon with Malaria (aside from Petechiae in severe Falciparum Malaria with DIC)
  5. Lymphadenopathy
    1. See Lymphadenitis in the Febrile Returning Traveler
  6. Myalgia
    1. Malaria (mild to moderate Muscle pain and tenderness)
    2. Dengue Fever (severe Muscle pain)
    3. Leptospirosis (severe tenderness)
    4. Typhus (severe tenderness)

XII. Exam: Focal areas

  1. Vital Signs
    1. See Pulse-Temperature Dissociation
    2. Pulse slower than normal for fever degree (pulse fails to increase with fever spike)
      1. Seen with Typhoid Fever, Rickettsial infection
  2. Eye Exam
    1. Ocular Larva Migrans
    2. Leptospirosis (Conjunctivitis)
  3. Lymph Node Exam
    1. See Lymphadenopathy in the Febrile Returning Traveler
  4. Cardiopulmonary Exam
    1. Subacute Bacterial Endocarditis
  5. Abdominal Exam
    1. See GI Conditions in Febrile Returning Traveler
  6. Neurologic Exam
    1. See Neurologic Findings in the Febrile Returning Traveler
    2. Altered Mental Status in Febrile Returning Traveler (medical emergency)
    3. Seizures in Febrile Returning Traveler
  7. Skin Exam
    1. See Cutaneous Conditions in Febrile Returning Traveler

XIII. Labs

  1. Complete Blood Count (CBC) with differential
    1. Observe for Eosinophilia (non-specific)
      1. Typically positive with Helminth infection, but not for protozoa
    2. Manual differential (standard with Wright stain)
      1. Test Sensitivity for Malaria approaching that of thin smear (Giemsa stain)
  2. Serum Electrolytes with Glucose
  3. Renal Function tests including Blood Urea Nitrogen
  4. Liver Function Tests
  5. Malaria thick and thin smears (Giemsa stain) x3, 12 hours apart
  6. Serologies as indicated
  7. Serum sample spun and saved for later Antibody titers
  8. Consider Dengue Fever IgM, IgG and virus detection
    1. Diagnose and start treatment based on clinical findings if suspected
    2. Use labs only for confirmation
  9. Cultures
    1. Urine Culture
    2. Blood Culture
    3. Stool Culture (including Salmonella typhi)
  10. Cerebrospinal Fluid Examination
    1. Indicated in Altered Mental Status and fever
    2. Exclude Meningitis and Encephalitis

XIV. Management

  1. Consider Infectious Disease Consultation
  2. Consider empiric antibiotic coverage until diagnosis
    1. Example: Doxycycline 100 mg PO qd

XV. Prevention

  1. See Travel Preparation

XVI. Resources

  1. CDC Yellow Book
    1. https://wwwnc.cdc.gov/travel/yellowbook/2018/post-travel-evaluation/fever-in-returned-travelers
  2. CDC National Notifiable Diseases (2018)
    1. https://wwwn.cdc.gov/nndss/conditions/notifiable/2018/
  3. CDC Current Outbreak List
    1. https://www.cdc.gov/outbreaks/index.html

XVII. References

  1. Anderson (2014) Crit Dec Emerg Med 28(7): 11-9
  2. Black, Martin, DeVos (2018) Crit Dec Emerg Med 32(8): 3-12
  3. Mason and Marsh in Herbert (2019) EM:Rap 19(5): 12-3
  4. Walker (2001) HP Primary Care Medicine Lecture
  5. Feder (2013) Am Fam Physician 88(8): 524-30 [PubMed]
  6. Lo Re (2003) Am Fam Physician 68(7):1343-50 [PubMed]
  7. Suh (1999) Med Clin North Am 83(4):997-1017 [PubMed]

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