Fever on Return from Abroad

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.

Malaria must be excluded if there has been travel through an endemic area (most of Africa, Asia, Central and South America). Malaria is the most common single cause of fever requiring admission to hospital after travel to the tropics, accounting for 40–60% of cases from sub-Saharan and West Africa and about 10% from Southeast Asia. Its clinical features are non-specific, and diagnosis requires examination of blood films for parasites, supplemented by rapid diagnostic tests. Chemoprophylaxis against malaria does not ensure full protection and may prolong the incubation period.
Other common causes of fever in travellers include respiratory and gastrointestinal infections. Arboviruses such as dengue, chikungunya and Zika virus infections are widespread, and enteric fevers (typhoid and paratyphoid) are common, particularly in Asia and the Indian subcontinent. Tick typhus is common in visitors to Africa.
For travellers who have returned within 21 days from rural west Africa and central Eurasia (especially Afghanistan and rural Pakistan), a viral haemorrhagic fever must be considered. Isolate the patient and follow local and national protocols for investigation. Seek advice from local infection and public health specialists and consult the national Imported Fever Service in the UK.
Consider other causes of febrile illness unrelated to travel, such as influenza, community-acquired pneumonia (Chapter 62) and urinary tract infection (Chapter 80)

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

Septic Shock
Chest X-Ray Shadowing
Meningism
Jaundice
Diarrhoea
Eosinophilia

This will depend on the clinical syndrome and likely pathogens.

Septic Shock

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

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

Meningism

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

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

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

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.

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Information ⬇

Priorities ⬆ ⬇

Further Management ⬆ ⬇

Further Reading ⬆