Fever in a returning traveller

EBM Klinik protokolları

16.02.2017 • Sonuncu dəyişiklik 16.02.2017

HeliSiikamäki

Quick Reference

Essentials

A traveller may fall ill with the same diseases as in the home country.
Traveller's diarrhoea is the most common infection associated with travelling. Respiratory infections keep the second place.
Life-threatening diseases such as sepsis and malaria have to be diagnosed and treated immediately. Fever in a traveller arriving from the tropics, particularly from tropical Africa, should be considered as malaria until proven otherwise.
The patient should readily be referred further to a larger regional hospital or to a teaching hospital for emergency investigations. If the patient is treated as an outpatient he/she should be followed-up.
Consult the infection specialist of your own region when needed.

Diagnostic workup for fever in travellers

Immediate hospital referral is necessary if the general condition of the patient is deteriorated or if the clinical examination reveals alarming findings, such as symptoms of bleeding, symptoms from the central nervous system, difficulty breathing, low blood pressure, hepatic or renal insufficiency, severe anaemia, thrombopenia or agranulocytosis, or if malaria is possible according to the history.
The following issues are enquired and documented
- exact travelling history in chronological order (destinations and schedule) from the preceding 6 months, or even years if symptoms are prolonged
- symptoms and when they appeared, in chronological order
- exposure to infections (unprotected sex, injections and blood transfusions, insect bites, tick bites, animal contacts, contacts with fresh water, use of unpasteurized milk products
- medications and possible treatments during the travel
- prophylactic vaccinations and their schedule
- malaria prophylaxis and its regularity
- symptoms in possible travelling companions
- abuse of drugs and alcohol.
Careful clinical examination, including inspection of the skin in good lighting
Laboratory and x-ray examinations
- Peripheral blood thin smear and thick smear to detect malaria. At least one blood smear should be examined immediately in the nearest laboratory. This should be done even if an antigen detection test (rapid test) were used to support the microscopic examination. If the first sample is negative, a new sample is taken after 4 to 6 hours and also during a temperature spike. At least 3 or 4 negative samples are required before malaria may be excluded.
- Blood culture × 2
- Plasma potassium, sodium and creatinine
- Rapid test for influenza, if there are respiratory symptoms
- HIV test
- Faecal bacterial cultures
- Chest x-ray
Table presents diseases to be remembered according to symptoms. The most probable cause (often not a tropical disease) is presented in bold type.
See also tables and .

Clues to the aetiology of a febrile disease based on the clinical presentation (in rough order of frequency)
Clues from the clinical presentation
Lung infection
Pneumonia Influenza Legionellosis — Fever, headache, myalgia, confusion, abdominal pain, diarrhoea Q fever — Fever, headache, myalgia, increased liver enzymes Melioidosis — Acute septic infection, dense pulmonary infiltrate Endemic deep mycoses (histoplasmosis, coccidioidomycosis, paracoccidioidomycosis, blastomycosis) — Areas of greatest risk: North, Central and South America Pulmonary anthrax — Mediastinitis
Fever, general symptoms without local manifestations
Malaria — Thrombopenia, leucopenia, increased CRP and liver enzymes Dengue fever — Thrombopenia, leucopenia, low CRP, increased liver enzymes, often mild skin rash Primary HIV — Thrombopenia, leucopenia, low CRP, increased liver enzymes, skin rash possible Typhus — Headache, dry cough, leucocytes and CRP slightly increased or normal Spotted fever — Skin rash, eschar, slightly increased or normal leucocytes and CRP Leptospirosis — Symptoms resembling influenza, hepatitis or meningitis, history of contact with fresh water, increased leucocytes, CRP and creatine kinase (CK) Acute schistosomiasis — History of contact with fresh water, eosinophilia Brucellosis — Lymphadenopathy, hepatosplenomegaly, arthritis, osteitis Visceral leishmaniasis — Lymphadenopathy, hepatosplenomegaly, pancytopenia Relapsing fever — Repeated fever episodes Trypanosomiasis — History of tsetse fly sting in Africa and a chancre
Encephalitis
Herpes encephalitis Kumlinge tick-borne encephalitis Japanese encephalitis Trypanosomiasis
Diarrhoea
Gastrointestinal bacterial infections: EAEC, EPEC, ETEC, Salmonella, Shigella, Campylobacter, Clostridium difficile, etc. Gastrointestinal parasitic infections: amoebiasis , giardiasis , cryptosporidiosis Hepatitis, particularly hepatitis A and E Malaria
Jaundice
Alcoholic hepatitis Viral hepatitis Malaria Epstein–Barr virus infection Cytomegalovirus infection Typhus Leptospirosis Q fever Epstein–Barr virus infection Cytomegalovirus infection
Delirium
Encephalitis or meningitis Malaria Any septic infection Abuse of drugs or alcohol Mefloquine used as prophylaxis against malaria
Bleeding diathesis
Dengue haemorrhagic fever — Thrombopenia, leucopenia, increased liver enzymes, skin rash Yellow fever — History of residing in tropical Africa or South America Ebola, Marburg, Lassa, Crimean-Congo haemorrhagic fever , no vaccination — History of residing in an epidemic area during the preceding 21 days and a close contact with a diseased person or animal — In Crimean-Congo haemorrhagic fever: tick bite

Fevers occurring in the tropics
Fevers occurring in the tropics
Common and endemic in large areas
Malaria Dengue fever Typhoid fever Viral hepatitis HIV infection Syphilis Tuberculosis
Rarer diseases that occur in large areas
Rickettsioses Amoebic liver abscess Brucellosis Schistosomiasis Toxoplasmosis Leptospirosis Rickettsioses "?> Filariasis
Rarer diseases that occur in limited areas
Melioidosis Visceral leishmaniasis Relapsing fever Trypanosomiasis Poliomyelitis Plague Haemorrhagic fevers Yellow fever

Incubation times of some of the fevers possibly acquired by travellers
Incubation time	Disease
Usually less than 10 days Symptoms may appear months or even years from infection
Short incubation time (less than 7 days)	Traveller's diarrhoea
	Dengue fever and other arbovirus infections
	Influenza
Medium long incubation time (less than 21 days)	Malaria
	Measles
	Hepatitis A
	Rickettsioses¹
	Typhoid fever
	Leptospirosis
	Haemorrhagic fevers
Long incubation time (more than 21 days)	Malaria²
	Viral hepatitis (A, B, C, D, E)
	Amoebic liver abscess
	Acute HIV infection
	Secondary syphilis
	Brucellosis
	Tuberculosis²
	Acute schistosomiasis
	Visceral leishmaniasis

Related resources

Literature

Ədəbiyyat

Siikamäki HM, Kivelä PS, Sipilä PN et al. Fever in travelers returning from malaria-endemic areas: don't look for malaria only. J Travel Med 2011;18(4):239-44.
Wilson ME, Freedman DO. Etiology of travel-related fever. Curr Opin Infect Dis 2007;20(5):449-53.
Wilson ME, Weld LH, Boggild A et al. Fever in returned travelers: results from the GeoSentinel Surveillance Network. Clin Infect Dis 2007;44(12):1560-8.
Bottieau E, Clerinx J, Schrooten W et al. Etiology and outcome of fever after a stay in the tropics. Arch Intern Med 2006;166(15):1642-8.
Freedman DO, Weld LH, Kozarsky PE et al. Spectrum of disease and relation to place of exposure among ill returned travelers. N Engl J Med 2006;354(2):119-30.
D'Acremont V, Ambresin AE, Burnand B et al. Practice guidelines for evaluation of Fever in returning travelers and migrants. J Travel Med 2003;10 Suppl 2():S25-52.