the febrile returned traveller

see also:

• travel medicine
• The febrile adult presenting to the ED
• traveller's diarrhoea
• Department of Public Health and Tropical Medicine at James Cook University, Townsville
• The Travel Clinic website
• The Travel Clinic's fact sheets for travelers
• http://www.smartraveller.gov.au/Aust Govt Smart Traveller website
• United States Centers for Disease Control and Prevention
• World Health Organization
• International Society of Travel Medicine (ISTM)

• infections in the returned traveller:
  • 50% of travellers returning to Europe and North America from the tropics experience health problems related to their travel, and 8% consult doctors either abroad or on return
  • 90% of infections related to short-term travel present within six months of return
  • older travellers are more likely to have a febrile complication of underlying disease, such as endocarditis or pneumonia.
  • typhoid and paratyphoid - typhoid vaccine confers about 70% protection for typhoid, so does not rule out the diagnosis
  • malaria - esp. West Africa (2%), Nigeria (1.3%), the Solomon Islands (1.1%), Ghana (0.6%) and Papua New Guinea (0.4%) without prophylaxis. TEST ALL FEBRILE travellers from endemic regions within past 12 months.
  • dengue fever - maculopapular rash, thrombocytopenia and leukopenia
  • zika virus and other arthropod borne viral infections
  • traveller's diarrhoea (35% incidence per month of travel)
    • most due to enterotoxigenic Escherichia coli (ETEC).
  • acute respiratory infections
  • giardiasis (0.7%)
  • hepatitis
  • amoebiasis
  • gonorrhoea and other sexually transmitted infections (STDs/STIs)
  • tuberculosis (TB) occurs in 2% of long-term travellers to high risk areas (subSaharan Africa, Nth Africa, Sth and East Asia, Middle East, Central and Sth America)
  • animal bites - rabies
  • delayed presentations months later:
    • strongyloidiasis, schistosomiasis, malaria due to Pl. vivax
  • MJA 2002 article - infections in the returned traveller
• multi-resistant bacteria an increasing problem
  • Asia has high rates of resistant intestinal bacteria which may create issues for travelers if they acquire it (eg. over 80% will become carriers of carbapenem-resistant enterobacteriaceae (CRE) after a 2 week admission in Vietnam and 10% of ED patients were colonized with CRE according to a 2019 study¹⁾) and then develop UTI, etc.
  • multidrug-resistant tuberculosis (TB) is endemic in many regions - according to WHO in 2017, each year around 0.5 million people will acquire it annually with highest rates in eastern Europe, then China, Middle East, and Peru ²⁾

• resuscitate as usual for severe sepsis
• blood cultures x2
• malaria films
• penicillin or ceftriaxone if meningitis likely
• then as below

• travel history - regions, dates, immunisations, check incubation periods
• pattern of fever occasionally helpful - every 2 days for Pl. vivax
• focal features eg. memingism, pneumonia, etc.
• rash
• investigations such as:
  • FBE, U&E, LFTs, blood cultures x 2, baseline serology
  • CXR
  • MSU m/c/s
  • specific Ix for focal findings
  • if possible malaria
    • thick and thin blood films, if negative, repeat 3 times
  • if rash
    • consider DDx as below
  • if respiratory symptoms:
    • if within 3 days of return, consider influenza
    • if pulmonary consolidation, consider legionaire's, meliodosis, and if severe, consider giving macrolide or quinolone
  • if fever > 7 days:
    • rule out malaria
    • consider empirical Rx for possible typhoid enteric fever
  • if jaundiced:
    • consider acute hepatitis including EBV / glandular fever / infectious mononucleosis, dengue, Q fever
    • acute cholangitis (stones, flukes)
    • liver abscess (amoebic, pyogenic)

• dengue fever
• typhoid and paratyphoid
• rickettsia (eg. scrub typhus, and perhaps African tick bite fever and Mediterranean and Rocky Mountain spotted fever)
• HIV / AIDS seroconversion
• Q fever
• meningococcal septicaemia
• toxic shock syndrome
• measles
• secondary syphilis
• rubella
• leishmaniasis causes this but without the rash

• incidence in returned travellers from the tropics is ~5%
• it is suggestive of parasite infection such as a helminth infection although the absence of eosinophilia does not exclude helminth infection as less than half have eosinophilia

• strongyloidiasis
• filariasis
• hookworm
• schistosomiasis
• cutaneous larva migrans
• ascariasis

• three stool examinations for ova, cysts and parasites to detect the more common gastrointestinal helminths, whose eggs may be excreted intermittently
• any macroscopically visible worms (likely to be ascarids or tapeworm) should be sent for laboratory identification
• specific serological testing is available for schistosomiasis, strongyloidiasis, filariasis, echinococcosis, toxocariasis and angio-strongyliasis

• start Rx after stool collections
• options include mebendazole, pyrantel and albendazole although of these, only albendazole is useful for strongyloidiasis, tapeworm infection or schistosomiasis.