Fever in the Returning Traveler

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

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II. Precautions: Malaria risk

  1. Fever in a returning traveler from Malaria endemic area is 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. This is an emergent evaluation
  2. Other common causes in the differential of Malaria
    1. Hepatitis
    2. Typhoid
    3. Dengue Fever

III. 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

IV. 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]

V. Causes: Geographic regions

  1. Caribbean
    1. Malaria (Haiti)
    2. Dengue Fever
    3. Also consider acute Histoplasmosis, Leptospirosis
  2. Central America and South America
    1. Malaria (primarily Plasmodium vivax)
    2. Dengue Fever
    3. Also consider Leptospirosis, Histoplasmosis, Coccidioidomycosis, Bartonellosis
  3. South Central Asia
    1. Malaria (typically NOT Plasmodium falciparum)
    2. Dengue Fever
    3. Enteric Fever (Salmonella typhi and paratyphi)
    4. Also consider Chikungunya virus
  4. Southeast Asia
    1. Malaria (typically NOT Plasmodium falciparum)
    2. Dengue Fever
    3. Also consider Chikungunya virus, Leptospirosis
  5. Sub-Saharan Africa
    1. Malaria (mostly Plasmodium falciparum)
    2. Tick-borne Rickettsiae
    3. Acute Schistosomiasis
    4. Filariasis
    5. Also consider african trypanosomiasis
  6. West Africa (Liberia, Sierra Leone, Guinea)
    1. Ebola (as of 2014)
  7. References
    1. See CDC Yellow Book resource below

VI. 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. Schistosomiasis
    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

VII. 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
  2. Incubation 7-21 days
    1. Leptospirosis
    2. Viral hemorrhagic fevers (including Ebola)
    3. Malaria (common)
    4. Enteric Fevers
      1. Typhoid Fever (common)
      2. Paratyphoid
    5. Typhus
    6. East African Trypanosomiasis
    7. Q Fever
  3. Incubation >21 days
    1. Human Immundeficiency Virus (HIV)
    2. Hepatitis A (common) 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)

VIII. History

  1. Travel itinerary
    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)?
  2. Exposures
    1. Insects (e.g. ticks, Mosquitos)
      1. See Vector Borne Disease
    2. Animal exposures
    3. Skin Trauma
    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
      1. See Waterborne Illness
  3. Medications
    1. New medications (especially immune compromising medications)
    2. Pretravel antibiotic prophylaxis (e.g. Mefloquine for Malaria Prophylaxis)
  4. Symptoms
    1. Fever
    2. Cough
    3. Abdominal Pain
    4. Diarrhea
    5. Rash

IX. 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 Altered Mental Status in Febrile Returning Traveler
    2. Altered Level of Consciousness in a returning febrile patient is a medical emergency (consider cerebral Malaria, or Hemorrhagic Shock)
  7. Skin Exam
    1. See Cutaneous Conditions in Febrile Returning Traveler

X. 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)

XI. Management

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

XII. Prevention

  1. See Travel Preparation

XIII. Resources

  1. CDC Yellow Book
    1. http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-5-post-travel-evaluation/fever-in-returned-travelers

XIV. References

  1. Anderson (2014) Crit Dec Emerg Med 28(7): 11-9
  2. Walker (2001) HP Primary Care Medicine Lecture
  3. Feder (2013) Am Fam Physician 88(8): 524-30 [PubMed]
  4. Lo Re (2003) Am Fam Physician 68(7):1343-50 [PubMed]
  5. Suh (1999) Med Clin North Am 83(4):997-1017 [PubMed]

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