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Fever in a Return Traveler

Madelaine Behrens

Background

  • Treatment of fever in a return traveler will depend on where the traveler came from and what risk their fever poses to themselves or others.

Presentation

  • Is the pt sick? AMS, tachypneic, hypotensive
  • Do they have signs of severe disease? Cyanosis, meningism (nuchal rigidity, photophobia, headache), peritonitis, digital gangrene
  • History Pearls
    • Obtain travel history: location(s), activities, purpose of travel, accommodations
    • Did they visit a friend or relative? (less likely to seek pretravel medical advice, higher risk for malaria, typhoid fever, tuberculosis, hepatitis A, and STD)
    • Were they hospitalized abroad? (consider MDR organisms)
  • Physical Exam Pearls
    • Skin rash with or without conjunctivitis (i.e., measles, meningococcemia, hemorrhagic fevers such as Ebola)
    • Rapid respiratory rate (i.e., influenza, Middle East respiratory syndrome [MERS], pneumonic plague)
    • Persistent cough (i.e., TB, pertussis)
    • Decreased consciousness (i.e., meningococcal meningitis, rabies)
    • Bruising or unusual bleeding without previous injury (i.e., hemorrhagic fevers)
    • Persistent voluminous diarrhea (i.e., cholera)
    • Persistent vomiting other than air or motion sickness (i.e., norovirus)
    • Jaundice (i.e., hepatitis A)
    • Flaccid paralysis of recent onset (polio)

Evaluation

  • Are you suspicious for a possible high-risk infection? Isolate, report to health department as appropriate
  • Most common serious cause of fever is malaria falciparum: order thick and thin blood smears. If negative, repeat the test.
  • Viral hemorrhagic fevers such as Ebola, Crimean–Congo hemorrhagic fever, Marburg hemorrhagic fever, and Lassa fever are highly transmissible and require immediate treatment
  • Incubation periods:
    • <21 days: East African trypanosomiasis, dengue, Japanese encephalitis, leptospirosis, malaria, meningococcemia, nontyphoidal salmonellosis, plague, typhoid fever, typhus, viral hemorrhagic fevers, yellow fever
    • >21 days: acute HIV, acute systemic schistosomiasis, amebic liver abscess, borreliosis (relapsing fever), brucellosis, leishmaniasis, malaria (esp after ineffective prophylaxis), rabies, TB, viral hepatitides, West African trypanosomiasis,
  • Fever pattern and course (not always helpful), notable exceptions include - Relapsing fevers (fever spikes separated by days or weeks): borreliosis, malaria - 48 hour interval fevers: plasmodium vivax or P ovale - 72 hour fevers: Plasmodium malariae - intermittent, unsynchronized: P falciparum
  • Initial labs: CBC, CMP, blood cx, rapid tests for malaria and dengue, PCR testing of plasma sample (for tick borne), CXR, blood smear (thick and thin), UA with microscopy and culture. Consider O &P, head imaging or LP, or additional abdominal imaging in the right clinical context.
  • Don’t forget the common causes of fever (could have nothing to do with pt’s travel)
  • Look up current outbreaks to help guide clinical suspicion. https://www.who.int/emergencies/disease-outbreak-news