Fever in the Returning Traveler

1. Precautions
   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. This is an emergent evaluation
   2. Other common causes in the differential of Malaria: Hepatitis, Typhoid, DengueFever
2. 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
3. Causes: Exposure Related Febrile Illnesses
   1. Sexually Transmitted Disease
      1. Gonorrhea
      2. Human Immunodeficiency Virus (HIV)
      3. Syphilis
      4. Hepatitis BVirus
      5. Chancroid
   2. Vector Contact
      1. See Vector Borne Disease
      2. Mosquitoes
         1. Malaria
         2. DengueFever
      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
   4. Infected Person Contact
      1. Viral hemorrhagic fever
      2. Enteric Fever
      3. Meningococcal infection
      4. Tuberculosis
   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
   8. Barefoot Exposure
      1. Strongyloidiasis
      2. Cutaneous Larva Migrans
4. Causes: Incubation Periods
   1. Incubation <10 days
      1. Traveler's Diarrhea
      2. DengueFever (common)
      3. Yellow Fever
      4. Spotted Fever
      5. Meningococcemia
   2. Incubation <21 days
      1. Leptospirosis
      2. Viral hemorrhagic fevers
      3. Malaria (common)
      4. Enteric Fevers
         1. Typhoid Fever (common)
         2. Paratyphoid
      5. Typhus
      6. East African Trypanosomiasis
   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. Leishmaniasis
      10. Systemic Schistosomiasis
5. Signs: Focal areas for examination
   1. Vital Signs
      1. See Pulse-Temperature Dissociation
   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. Altered Mental Status in Febrile Returning Traveler
   7. Skin Exam
      1. Cutaneous Conditions in Febrile Returning Traveler
6. Labs
   1. Complete Blood Count (CBC) with differential
      1. Observe for Eosinophilia
   2. Serum Electrolytes with Glucose
   3. Liver Function Tests
   4. Malaria thick and thin smears x3, 12 hours apart
   5. Serologies as indicated
   6. Serum sample spun and saved for later Antibody titers
   7. Cultures
      1. Urine Culture
      2. Blood Culture
      3. Stool Culture
7. Management
   1. Consider Infectious Disease Consultation
   2. Consider empiric antibiotic coverage until diagnosis
      1. Example: Doxycycline 100 mg PO qd
8. Prevention
   1. See Travel Preparation
9. References
   1. Walker (2001) HP Primary Care Medicine Lecture
   2. Lo Re (2003) Am Fam Physician 68(7):1343-50
   3. Suh (1999) Med Clin North Am 83(4):997-1017