II. Precautions: Malaria risk

  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. Especially consider Malaria with Leukopenia and Left Shift, Thrombocytopenia
    3. Up to 50% of Malaria cases are misdiagnosed on the first visit
    4. This is an emergent evaluation
  2. Other common causes in the differential of Malaria
    1. Hepatitis
    2. Typhoid
    3. Dengue Fever

IV. Causes: By frequency in febrile travelers returning to developed countries

  1. Malaria (21%)
  2. Febrile Diarrhea (15%)
  3. Febrile respiratory infections (14%)
  4. Dengue Fever (6%)
  5. Non-Diarrheal, febrile gastrointestinal illness (5%)
  6. Fever with rash (4%)
  7. Genitourinary infections with fever (4%)
  8. Ricckettsia (2%)
  9. Typhoid Fever or Paratyphoid Fever (2%)
  10. Wilson (2007) Clin Infect Dis 44(12): 1560-8 [PubMed]

V. Causes: Geographic regions

  1. Caribbean
    1. Malaria (Haiti)
    2. Dengue Fever
    3. Also consider acute Histoplasmosis, Leptospirosis
  2. Central America and South America
    1. Malaria (primarily Plasmodium vivax)
    2. Dengue Fever
    3. Also consider Leptospirosis, Histoplasmosis, Coccidioidomycosis, Bartonellosis
  3. South Central Asia
    1. Malaria (typically NOT Plasmodium falciparum)
    2. Dengue Fever
    3. Enteric Fever (Salmonella typhi and paratyphi)
    4. Also consider Chikungunya virus
  4. Southeast Asia
    1. Malaria (typically NOT Plasmodium falciparum)
    2. Dengue Fever
    3. Also consider Chikungunya virus, Leptospirosis
  5. Sub-Saharan Africa
    1. Malaria (mostly Plasmodium falciparum)
    2. Tick-borne Rickettsiae
    3. Acute Schistosomiasis
    4. Filariasis
    5. Also consider african trypanosomiasis
  6. West Africa (Liberia, Sierra Leone, Guinea)
    1. Ebola (as of 2014)
  7. References
    1. See CDC Yellow Book resource below

VI. Causes: Exposure Related Febrile Illnesses

VII. Causes: Incubation Periods

  1. Incubation <7-10 days
    1. Traveler's Diarrhea
    2. Dengue Fever (common)
    3. Yellow Fever
    4. Spotted Fever (Rickettsiae)
    5. Meningococcemia
    6. Chikungunya
  2. Incubation 7-21 days
    1. Leptospirosis
    2. Viral hemorrhagic fevers (including Ebola)
    3. Malaria (common)
    4. Enteric Fevers
      1. Typhoid Fever (common)
      2. Paratyphoid
    5. Typhus
    6. East African Trypanosomiasis
    7. Q Fever
  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. Visceral Leishmaniasis
    10. Systemic Schistosomiasis (Katayama)

VIII. History

  1. Travel itinerary
    1. Who did you see (family, wildlife, farm animals)?
    2. Where did you travel (what country, what environments, what living conditions)?
    3. When did you travel and for how long?
    4. What did you do (wilderness travel, mission work, farm work, construction)?
  2. Exposures
    1. Insects (e.g. ticks, Mosquitos)
      1. See Vector Borne Disease
    2. Animal exposures
    3. Skin Trauma
    4. Contagious contacts (in travel country or home country)
    5. Sexual transmitted infection risk or exposure while traveling
    6. Food sources of infection
      1. See Foodborne Illness
    7. Water sources of infection
      1. See Waterborne Illness
  3. Medications
    1. New medications (especially immune compromising medications)
    2. Pretravel antibiotic prophylaxis (e.g. Mefloquine for Malaria Prophylaxis)
  4. Symptoms
    1. Fever
    2. Cough
    3. Abdominal Pain
    4. Diarrhea
    5. Rash

IX. Exam: Focal areas

X. Labs

  1. Complete Blood Count (CBC) with differential
    1. Observe for Eosinophilia
    2. Manual differential (standard with Wright stain) has Test Sensitivity for Malaria approaching that of thin smear (Giemsa stain)
  2. Serum Electrolytes with Glucose
  3. Renal Function tests including Blood Urea Nitrogen
  4. Liver Function Tests
  5. Malaria thick and thin smears (Giemsa stain) x3, 12 hours apart
  6. Serologies as indicated
  7. Serum sample spun and saved for later Antibody titers
  8. Consider Dengue Fever IgM, IgG and virus detection
    1. Diagnose and start treatment based on clinical findings if suspected
    2. Use labs only for confirmation
  9. Cultures
    1. Urine Culture
    2. Blood Culture
    3. Stool Culture (including Salmonella typhi)

XI. Management

  1. Consider Infectious Disease Consultation
  2. Consider empiric antibiotic coverage until diagnosis
    1. Example: Doxycycline 100 mg PO qd

XII. Prevention

XIV. References

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