Fever in a Return Traveler

Allison Taffet

Background 

  • Differential and treatment vary based on location of travel 
  • Consider illnesses endemic to the US that are transmitted in crowds (mono, flu, cold, etc.) 
  • Always consider malaria if endemic (regardless of prophylaxis)

Presentation 

  • Red flags: Cyanosis, meningismus, peritonitis, digital gangrene, AMS, bruising, bleeding 
  • Thorough history: Locations, activities, accommodations, consumption of unclean water or risky foods, insect/tick bites, animal exposures, sex 
    • Visiting friend/relative (less likely to seek pretravel medical advice, higher risk for malaria, typhoid fever, tuberculosis, hepatitis A, and STD) 
    • Hospitalization/medical treatment abroad (consider MDR organisms) 
  • Evaluate immunization status and chemoprophylaxis received before/during travel. CDC Yellow Book: https://www.cdc.gov/yellowbook/ index.html

Differential by Region

  • Latin America/ Caribbean: Malaria (P vivax), Dengue, chikungunya, leptospirosis, yellow fever, Zika, Typhoid, Leishmaniasis, Coccidioides, Bartonella 
  • Southeast Asia: Dengue, chikungunya, malaria, scrub typhus, leptospirosis 
  • Sub-Saharan Africa: Malaria (P falciparum), Dengue, chikungunya, Rickettsial diseases, yellow fever, schistosomiasis, Typhoid fever, African trypanosomiasis 
  • Domestic travelers: tickborne illness (ehrlichia, anaplasmosis, STARI, Lyme, RMSF), coccidiomycosis (SW US), histo, blasto, crypto, tularemia, hantavirus, legionella 
  • Current outbreaks: https://www.who.int/emergencies/disease-outbreak-news

Differential by Exposure

  • Cruise ships/resort: legionella, norovirus 
  • Farms: brucellosis, Q fever 
  • Water: leptospirosis, schistosomiasis, amebiasis, cholera, hepatitis, salmonella

Clinical Syndrome

  • Bacterial: 
    • Legionellosis: Fever w/ relative bradycardia + atypical PNA + diarrhea + hyponatremia 
    • Leptospirosis: Flu-like sx + conjunctival suffusion + jaundice o Typhus: Flu-like sx + rash + N/V + thrombocytopenia 
    • Typhoid fever: Fever w/ relative bradycardia + diarrhea +/- rosy rash +/- AMS 
    • Q fever: Flu-like sx + atypical PNA + hepatomegaly 
  • Viral: 
    • Dengue: Fever + rash + severe arthralgias (“breakbone fever”) + severe retro-orbital pain + petechiae after tourniquet test. May progress to severe/hemorrhagic due to thrombocytopenia 
    • Chikungunya: high fever + rash + severe bilateral joint pain w/ effusion 
    • Zika: flu-like symptoms + pruritic rash 
    • Yellow Fever: Flu-like sx w/ high fever + N/V. Hemorrhagic in 15% symptomatic pt o Viral hemorrhagic fevers: flu-like illness that progresses to bleeding 
  • Parasitic: 
    • Malaria: Flu-like sx + high fever (intermittent spiking F is rare) + hemolytic anemia with thrombocytopenia and normal WBC + often multi-organ involvement 
    • Leishmaniasis: painless reddish macules/papules w/ central ulceration. If fever, concerning for visceral leishmaniasis

Evaluation

  • Don’t forget common causes of fever (could have nothing to do with pt’s travel or could be routine infections seen in US) 
  • Initial labs: CBC w/diff, CMP, coags, BCx, rapid tests for malaria and dengue, PCR testing of plasma (for tick borne), CXR, blood smear (thick and thin), UA with micro and Cx. 
    • Consider O&P, head imaging or LP, or abdominal imaging in the right clinical context. 
  • Malaria: Order febrile traveler serum PCR. If (+), it will reflex to thick and thin blood smears 
    • If negative, order repeat smears over 24-72H after discussion with lab 
  • If any c/f viral hemorrhagic fevers (ie Ebola, Crimean–Congo hemorrhagic fever, Marburg hemorrhagic fever, and Lassa fever), notify VUMC Infection prevention IMMEDIATELY. Will require special precautions and protocols
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