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VilleHolmberg

Fever in a Returning Traveller

Essentials

  • A traveller may fall ill with the same diseases as in the home country.
  • Traveller's diarrhoea is the most common infection associated with travelling. Respiratory infections keep the second place.
  • Life-threatening diseases such as sepsis and malaria have to be diagnosed and treated immediately. Fever in a traveller arriving from the tropics, particularly from tropical Africa, should be considered as malaria until proven otherwise.
  • The patient should readily be referred further to a larger regional hospital or to a teaching hospital for emergency investigations. If the patient is treated as an outpatient he/she should be followed-up.
  • Consult the infection specialist of your own region when needed.

Diagnostic workup for fever in travellers

  • Immediate hospital referral is necessary if the general condition of the patient is deteriorated or if the clinical examination reveals alarming findings, such as symptoms of bleeding, symptoms from the central nervous system, difficulty breathing, low blood pressure, hepatic or renal insufficiency, severe anaemia, thrombopenia or agranulocytosis, or if malaria is possible according to the history.
  • The following issues are enquired and documented
    • exact travelling history in chronological order (destinations and schedule) from the preceding 6 months, or even years if symptoms are prolonged
    • symptoms and when they appeared, in chronological order
    • exposure to infections (unprotected sex, injections and blood transfusions, insect bites, tick bites, animal contacts, contacts with fresh water, use of unpasteurized milk products
    • medications and possible treatments during the travel
    • prophylactic vaccinations and their schedule
    • malaria prophylaxis and its regularity
    • symptoms in possible travelling companions
    • abuse of drugs and alcohol.
  • Careful clinical examination, including inspection of the skin in good lighting
  • Laboratory and x-ray examinations
    • Malaria plasmodia. See further information in article Diagnosis and treatment of malaria Diagnosis and Treatment of Malaria.
    • Blood culture × 2
    • Complete blood count and plasma CRP
    • Alanine aminotransferase, alkaline phosphatase and bilirubin in plasma
    • Potassium, sodium and creatinine
    • Rapid test for respiratory viruses (influenza A/B, RSV, COVID-19) i.e. point-of-care (POC) nucleic acid detection test, if there are respiratory symptoms
    • Test for COVID-19 infection
    • HIV antigen and antibodies
    • Chemical urinalysis
    • Combination of nucleic acid detection of faecal pathogens and faecal bacterial culture
    • Chest x-ray
  • Table T1 presents diseases to be remembered according to symptoms. The most probable cause (often not a tropical disease) is presented in bold type.
  • See also tables T2 and T3.

Clues to the aetiology of a febrile disease based on the clinical presentation (in rough order of frequency)

Clues from the clinical presentation
Lung infection
Pneumonia Pneumonia
Influenza Influenza
Coronavirus infection Covid-19 and other Coronavirus Infections
Legionellosis
- Fever, headache, myalgia, confusion, abdominal pain, diarrhoea
Q fever
- Fever, headache, myalgia, increased liver enzymes
Melioidosis
- Acute septic infection, dense pulmonary infiltrate
Endemic deep mycoses Deep Endemic Mycoses (histoplasmosis, coccidioidomycosis, paracoccidioidomycosis, blastomycosis)
- Respiratory tract symptoms and findings, skin findings possible
- Areas of greatest risk: North, Central and South America
Pulmonary anthrax Bacterial Diseases in Warm Climates
- Mediastinitis
Fever, general symptoms without local manifestations
Malaria Diagnosis and Treatment of Malaria
- Thrombopenia, leucopenia, increased CRP and liver enzymes
Dengue fever Viral Diseases in Warm Climates
- Thrombopenia, leucopenia, low CRP, increased liver enzymes, often mild skin rash
Chikungunya Viral Diseases in Warm Climates
- Thrombopenia, leucopenia, low CRP, increased liver enzymes, skin rash, arthritis
Primary HIV HIV Infection
- Thrombopenia, leucopenia, low CRP, increased liver enzymes, skin rash possible
Typhus Diarrhoeal Diseases Caused by Microbes
- Headache, dry cough, leucocytes and CRP slightly increased or normal
Spotted fever Bacterial Diseases in Warm Climates
- Skin rash, eschar, slightly increased or normal leucocytes and CRP
Leptospirosis Bacterial Diseases in Warm Climates
- Symptoms resembling influenza, hepatitis or meningitis, history of contact with fresh water, increased leucocytes, CRP and creatine kinase (CK)
Acute schistosomiasis Schistosomiasis (Bilharziasis)
- History of contact with fresh water, eosinophilia
Brucellosis Bacterial Diseases in Warm Climates
- Lymphadenopathy, hepatosplenomegaly, arthritis, osteitis
Visceral leishmaniasis Leishmaniases
- Lymphadenopathy, hepatosplenomegaly, pancytopenia
Relapsing fever Bacterial Diseases in Warm Climates
- Repeated fever episodes
Trypanosomiasis Trypanosomiases
- History of tsetse fly sting in Africa and a chancre
Encephalitis
Herpes encephalitis Encephalitis
Kumlinge tick-borne encephalitis Encephalitis
Japanese encephalitis Viral Diseases in Warm Climates
Trypanosomiasis Trypanosomiases
Diarrhoea
Gastrointestinal bacterial infections: EAEC, EPEC, ETEC, Salmonella, Shigella, Campylobacter, Clostridium difficile, etc. Acute Diarrhoeal Disease in a Traveller
Gastrointestinal parasitic infections: amoebiasis Amoebiasis, giardiasis Giardiasis, cryptosporidiosis Cryptosporidiosis, dientamoebiasis Dientamoebiasis in Adults
Hepatitis, particularly hepatitis A and E Viral Hepatitis
Malaria Diagnosis and Treatment of Malaria
Jaundice
Alcoholic hepatitis
Viral hepatitis Viral Hepatitis
Malaria Diagnosis and Treatment of Malaria
Epstein-Barr virus infection Mononucleosis
Cytomegalovirus infection
Typhus Diarrhoeal Diseases Caused by Microbes
Leptospirosis Bacterial Diseases in Warm Climates
Q fever Bacterial Diseases in Warm Climates
Delirium
Encephalitis Encephalitis or meningitis Meningitis in Adults
Malaria Diagnosis and Treatment of Malaria
Any septic infection Sepsis
Abuse of drugs or alcohol
Bleeding diathesis
Dengue haemorrhagic fever Viral Diseases in Warm Climates
- Thrombopenia, leucopenia, increased liver enzymes, skin rash
Yellow fever Viral Diseases in Warm Climates
- History of residing in tropical Africa or South America, no vaccination
Crimean-Congo haemorrhagic fever, Lassa, Ebola, MarburgViral Diseases in Warm Climates
- History of residing in an epidemic area during the preceding 21 days and a close contact with a diseased person or animal
- In Crimean-Congo haemorrhagic fever: tick bite

Fevers occurring in the tropics

Fevers occurring in the tropics
Common and endemic in large areas
Rarer diseases that occur in large areas
Rarer diseases that occur in limited areas

Incubation times of some of the fevers possibly acquired by travellers

Incubation timeDisease
Short incubation time (less than 7 days)Traveller's diarrhoea Acute Diarrhoeal Disease in a Traveller
Dengue fever, Chikungunya and other arbovirus infections Viral Diseases in Warm Climates
Influenza Influenza
Medium long incubation time (less than 21 days)Malaria Diagnosis and Treatment of Malaria
Measles Measles, Mumps and Rubella (MMR)
Hepatitis A Viral Hepatitis
Rickettsioses1 Bacterial Diseases in Warm Climates
Typhoid fever Diarrhoeal Diseases Caused by Microbes
Leptospirosis Bacterial Diseases in Warm Climates
Haemorrhagic fevers Viral Diseases in Warm Climates
Long incubation time (more than 21 days)Malaria2 Diagnosis and Treatment of Malaria
Viral hepatitis (A, B, C, D, E) Viral Hepatitis
Amoebic liver abscess Amoebic Abscess
Acute HIV infection HIV Infection
Secondary syphilis Syphilis
Brucellosis Bacterial Diseases in Warm Climates
Tuberculosis2 Diagnosing Tuberculosis
Acute schistosomiasis Schistosomiasis (Bilharziasis)
Visceral leishmaniasis Leishmaniases
  1. Usually less than 10 days
  2. Symptoms may appear months or even years from infection
References
Siikamäki HM, Kivelä PS, Sipilä PN et al. Fever in travelers returning from malaria-endemic areas: don't look for malaria only. J Travel Med 2011;18(4):239-44. [PubMed]
  • Wilson ME, Freedman DO. Etiology of travel-related fever. Curr Opin Infect Dis 2007;20(5):449-53. [PubMed]
  • Wilson ME, Weld LH, Boggild A et al. Fever in returned travelers: results from the GeoSentinel Surveillance Network. Clin Infect Dis 2007;44(12):1560-8. [PubMed]
  • Bottieau E, Clerinx J, Schrooten W et al. Etiology and outcome of fever after a stay in the tropics. Arch Intern Med 2006;166(15):1642-8. [PubMed]
  • Freedman DO, Weld LH, Kozarsky PE et al. Spectrum of disease and relation to place of exposure among ill returned travelers. N Engl J Med 2006;354(2):119-30. [PubMed]
  • D'Acremont V, Ambresin AE, Burnand B et al. Practice guidelines for evaluation of Fever in returning travelers and migrants. J Travel Med 2003;10 Suppl 2:S25-52. [PubMed]