Fever in a Return Traveler

Michael Daw

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.
  • ALWAYS remember to think about common US illnesses that are frequently transmitted due to exposure to crowds in airports, airplanes, bus stations, etc (mononucleosis (EBV and CMV), influenza, other common cold viruses, etc.)

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)
    • Consumption of unclean watee or risky foods, insect/tick bites, animal exposures, sexual contact
    • Were they hospitalized abroad? (consider MDR organisms)
    • Evaluate immunization status and chemoprophylaxis received before/during travel. Check out the CDC Yellow Book: https://www.cdc.gov/yellowbook/ index.html

Etiologies based on clinical syndrome

  • Skin rash with or without conjunctivitis and fever (i.e., measles, typhus, dengue, chikungunya (both dengue and chikungunya tend to also cause severe muscle and joint aches), Zika, meningococcemia, hemorrhagic fevers such as Ebola)
  • Rapid respiratory rate (i.e., influenza, Middle East respiratory syndrome [MERS], pneumonic plague, histoplasmosis)
  • Persistent cough (i.e., TB, pertussis, fungal infections like coccidioidomycosis, blastomycosis, histoplasmosis, cryptococcus)
  • Decreased consciousness (i.e., malaria, meningococcal meningitis, rabies, tickborne encephalitis)
  • Bruising or unusual bleeding without previous injury (i.e., hemorrhagic fevers)
  • Persistent voluminous diarrhea (i.e., campylobacter, shigella, salmonella – although many do not usually present with fever - Traveler’s diarrhea, cholera, giardiasis)
  • Persistent vomiting other than air or motion sickness (i.e., norovirus) o Jaundice (i.e., hepatitis A, B (if not vaccinated), D, E; leptospirosis)
  • Flaccid paralysis of recent onset (polio)
  • Genital lesions (HIV, G/C, hepatitis, syphilis, Mpox, hemorrhagic fevers, lymphogranuloma venereum) If no localizing symptoms, consider usual incubation periods:
  • <21 days: East African trypanosomiasis, dengue, Zika, chikungunya, 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,
  • 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 Domestic travelers (within the US), consider: tickborne illness (ehrlichia, anaplasmosis, STARI, Lyme, Rocky Mtn Spotted fever), coccidiomycosis, histoplasmosis, blastomycosis, cryptococcus, tularemia, hantavirus

Evaluation

  • Most common serious cause of fever from travel to certain areas is malaria falciparum: order thick and thin blood smears and note that the order is for malaria blood smear (if you order thick and thin w/o malaria order, it will not be done in an urgent manner). If negative, order repeat smears over 24-72 hrs.
  • Viral hemorrhagic fevers such as Ebola, Crimean–Congo hemorrhagic fever, Marburg hemorrhagic fever, and Lassa fever are highly transmissible and require immediate treatment. IF suspicious, VUMC Infection prevention should be notified IMMEDIATELY. Special precautions and protocols should be initiated to protect treating team. Initial labs: CBC w/diff, 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 or could be routine infections seen in US)
  • Empiric doxycycline is a reasonable adjunct for undifferentiated non-malaria fevers
  • Look up current outbreaks to help guide clinical suspicion. https://www.who.int/emergencies/disease-outbreak-news
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