Fever in a returning traveller

Introduction
Fever in returning travellers is common;
Fever may be a manifestation of a minor, self-limiting process, or a life threatening infection.

Key questions in the evaluation of such patients

Where has the patient travelled to?

This will determine the risk of exposure to specific infections.
The geographical region of travel and whether rural or urban environments, activities, diet,
sources of water and type of accommodation will determine the pathogens the patient has
potentially been exposed to.
It is important to ask which parts of the country the patient visited, and about soil and water
contact whilst there.
The dates of travel and duration of stay will determine the timing of potential exposure and
incubation period. Modes of transport, layovers and intermediate stops should also be asked
about. The history should mainly focus on the preceding year, as infections acquired before
this are unlikely to cause an acute febrile illness (although there are exceptions).

What pre-travel measures were taken?

Vaccines received prior to travel and any chemoprophylaxis taken will influence the likelihood
of some infections. A list of recommended vaccinations by country can be found on the CDC
website. Enquire about childhood vaccinations also; some may not have received a full
course. Vaccines vary in their efficacy, so vaccination against a particular infectious agent
does not necessarily exclude this from the differential diagnosis. Details of malaria
chemoprophylaxis should include drug, regimen, adherence and any gastrointestinal illness
that may have reduced the efficacy. Enquire about the duration of therapy prior to and on
returning from the endemic area.

Sexual history? Sexual contact with new partners is common during travel, and sexual tourism is
increasing. 19% of travellers have a new partner whilst away, and around 6% of these acquire a
sexually transmitted infection. History should include; number of new partners, use of barrier
contraception and type of sexual activity. Enquire about other potential exposures to blood or body
fluids including tattoos, piercings, dental or medical procedures and use of drugs.
Host factors? A general history should be taken alongside travel-specific questions, such as finding
out age and gender. Immunocompromised patients are susceptible to a broader range of pathogens;
risk of HIV exposure, current medications and any relevant past medical history should be included.
Timing of exposure and presentation? By determining when exposure to the pathogen occurred, it
is possible to determine an incubation period, so if greater than a month, many infections can be
excluded and others can be ruled in, as some infections (loa loa) require long term exposure. Different
infections have varying lengths of time till presentation is common, and this can help predict ailments.

Examination and Investigation

Examination: Thorough examination looking for a source of infection and any localising signs
indicating possible aetiology. In particular, skin lesions, lymphadenopathy, retinal or conjunctival
changes, hepatomegaly, splenomegaly, signs of anaemia, genital lesions and neurological
examination.
Investigations: Investigations for specific infections are given in the table.

Differential diagnosis
The most common infections causing systemic febrile illness in travellers are;

Malaria- this is covered in depth in a separate article. Any patient who has visited an
endemic area and gives a history of fever should be tested for malaria. Falciparum malaria
predominates in sub-saharan Africa and SE Asia, and can be fatal. Chemoprophylaxis decreases
the risk, but increasing resistance and poor adherence lower efficacy. The Plasmodium malariae
strain may present months or years after exposure, so may confuse a diagnosis. Malaria can act
as a great imitator and patients can present with unusual symptoms, so country of visit is used to
make the diagnosis, and infact malaria is assumed in a returning traveller until proven otherwise
due to its frequency and deadliness.

Dengue fever- found in many tropical and sub-tropical regions and has a very rapid onset.
No prevention is available, and treatment is supportive. Dengue haemorrhagic fever is caused by
the same virus.

Glandular fever- caused by EBV or CMV is commonly seen in returning travellers, and may be
acquired in the UK, and is very common in young travellers.

Enteric fevers- typhoid and paratyphi. From ingestion of contaminated food or water in many
regions.

Viral hepatitis- many are vaccinated against hepatitis A, however hepatitis E can also cause
an acute hepatitis and is also transmitted through contaminated food and water.

Undifferentiated fever: malaria, amoebic liver abscess, chikungunya, dengue, enteric fever,
leptospirosis, schistosomiasis
Fever with rash: Dengue, VHF, schistosomiasis
Fever with jaundice: leptospirosis, viral hepatitis, VHF, yellow fever
Fever with hepato/splenomegaly: malaria, amoebic liver abscess, brucellosis, leptospirosis,
trypanosomiasis, leishmaniasis
Fever with gastrointestinal symptoms: E. coli, Campylobacter, Salmonella, Shigella
Fever with respiratory symptoms: influenza, Streptococci, H. influenzae, TB
Fever with CNS symptoms: malaria, meningococcal, Japanese encephalitis, rabies, African
trypanosomiasis.
Less common causes of fever in travellers include schistosomiasis, onchocerciasis, African and South
American (Chagas) trypanosomiasis, Leishmaniasis, Japanese encephalitis and rabies. These are
outlined in the table below, and further details can be found in the Important tropical diseases article.
TB is more commonly seen in those living or visiting family in endemic areas. Viral haemorrhagic
fevers are rare, but occur in outbreaks and require rapid identification and management. Information
on current local disease patterns can be found on the WHO and CDC websites.

Alongside tropical infections, other causes of febrile illness should be considered. However antibiotic
resistance patterns may be different to those in the UK for organisms causing UTI, URTI etc. The
range of infections that may be acquired in developing countries is wide, but can be narrowed through
travel history and examination findings. 2% will have a non-infective cause of fever; a thorough history
and examination are necessary

Management
This depends entirely on the underlying condition, however the initial aims usually are
1) To exclude malaria as it is both one of the commonest and by far the most deadly, so the patient
is managed assuming they have malaria until proven otherwise
2) It needs to be established if the patient is infectious to others, especially if they have TB,
haemorrhagic fever or norovirus.
3) Sometimes due to the length of time for serology to return, a patient may begin treatment on
clinical grounds alone.
4) When prescribing antibiotics, in the absence of lab culture results to confirm resistance, it is
essential to consider patterns of antibiotic resistance from the visited country. This is very important
for TB and typhoid.
There are a few red flag symptoms that require urgent care if noticed in the febrile patient, these are:
1)

Haemmorhagic manifestations

2)

Respiratory distress

3)

Hypotension/ hemodynamic instability

4)

Confusion, lethargy, stiff neck or focal neurological signs