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Author(s): Nick Beeching and Mike Beadsworth

The management of the patient with a febrile illness within two months of travel abroad is summarized in Figure 33.1. See Box 33.1 for sources of advice on the diagnosis and management of infectious diseases acquired abroad.

Priorities

  • Admit to a single room and nurse with standard isolation technique until the diagnosis is established.
  • The focused assessment of the patient with fever on return from abroad is given in Table 33.1, and typical incubation periods for selected tropical infections in Table 33.2. Clinical features of malaria and enteric fever are summarized in Appendices 33.1 and 33.2.
  • Investigations needed urgently are given in Table 33.3.

Further Management

Outline


This will depend on the clinical syndrome and likely pathogens.

Septic Shock!!navigator!!

  • Initial antimicrobial therapy for patients who have travelled in endemic regions may need to cover falciparum malaria (Appendix ) and enteric fever (Appendix ). Typhoid, paratyphoid and many other bacterial infections acquired in the tropics are increasingly resistant to many antimicrobials, particularly if the traveller has been in the Middle East or Asia and/or in contact with healthcare settings while travelling. Quinolone resistance is common in Gram-negative organisms and resistance to cefalosporins and carbapenems is rapidly increasing, so local sepsis treatment policies may not be appropriate and infection specialists should be consulted to advise on empirical treatment until results of cultures and sensitivity patterns become available.
  • Empirical treatment for suspected enteric fever or gastroenteritis severe enough to merit antimicrobials is currently with azithromycin, or ceftriaxone for severe enteric fever.
  • Patients with severe falciparum malaria and hypotension should also receive antibiotics to cover Gram-negative infection, as mixed infections may occur. See Chapter 35 for the management of sepsis and septic shock.

Chest X-Ray Shadowing!!navigator!!

Consider pulmonary tuberculosis, SARS and MERS CoV, and Legionnaires' disease, in addition to the common causes of community-acquired pneumonia (Chapter 62).

Meningism!!navigator!!

  • See Chapter 68 for the management of suspected bacterial meningitis, and Chapter 69 for suspected encephalitis.
  • Perform a lumbar puncture, preceded by CT only if indicated.
  • If the CSF shows no organisms but a high lymphocyte count, consider tuberculous meningitis (Appendix ), leptospirosis or brucellosis.
  • If there are other features suggesting leptospirosis (haemorrhagic rash, conjunctivitis, renal failure, jaundice), give ceftriaxone or benzyl penicillin or doxycycline.

Jaundice!!navigator!!

  • See Chapter 23 for the assessment of the patient with acute jaundice.
  • Always consider falciparum malaria. Others causes are viral hepatitis A, B and E (but with these infections patients are usually afebrile when jaundice appears), leptospirosis, cytomegalovirus and Epstein-Barr virus infection, in addition to non-infectious causes, including drug and alcohol toxicity.

Diarrhoea!!navigator!!

  • See Chapter 22 for the management of the patient with acute diarrhoea.
  • Causes to consider following recent travel abroad are given in Table 22.5.

Eosinophilia!!navigator!!

The presence of eosinophilia in association with fever in returned travellers usually indicates an invasive helminth infection, but exclude other causes, especially atopy and drug reactions. Causes include filariasis (clues nocturnal or diurnal fever pattern); early phase of strongyloides and hookworm infections (abdominal pain, diarrhoea); hookworm and roundworm pneumonitis (cough, wheeze); early schistosomiasis (freshwater exposure especially in Africa/Middle East, urticarial rash, wheeze, altered semen); and loiasis (travel to Africa, transient peripheral skin swellings). Seek expert advice on special investigations needed.

Further Reading

Beeching NJ, Fletcher TE, Wijaya L (2013). Health problems in returned travellers. In Principles and Practice of Travel Medicine, 2nd edn. Ed. Jane N.Zuckerman .Blackwell Publishing Ltd. pp 260286.

Centers for Disease Control and Prevention: Traveler's Healths. https://www.cdc.gov/

Checkley AM, Chiodini PL, Dockrell DH, et al, for British Infection Society and Hospital for Tropical Diseases. Eosinophilia in returning travellers and migrants from the tropics: UK recommendations for investigation and initial management (2010). Journal of Infection , 60, 120.

Johnston V, Stockley JM, Dockrell D, et al, for British Infection Society and the Hospital for Tropical Diseases Fever in returned travellers presenting in the United Kingdom: recommendations for investigation and initial management (2009). Journal of Infection , 59, 118.

Kularatne SAM (2015). Dengue fever. BMJ 351, h4661. DOI: 10.1136/bmj.h4661.

Lalloo DG, Shingadia D, Bell DJ, Beeching NJ, Whitty CJM, Chiodini PL, for the PHE Advisory Committee on Malaria Prevention in UK Travellers (2016). UK malaria treatment guidelines. Journal of Infection 72, 635649.

Thwaites GE, Day NP (2017). Approach to fever in the returning traveler. New England Journal of Medicine , 376, 548560.