Fever in the returning traveler

The patient who returns from vacation with a fever is often a diagnostic dilemma. Unfortunately, up to 1 in 5 travelers to the developing world will get one within a few weeks of their trip. So how do you come up with a logical, evidence based diagnostic workup for a fever of unknown origin?

Thankfully, these authors reviewed the literature and came up with an easy to follow algorithm to work up a patient. It includes:

• Taking a detailed history
  • Dates of travel
  • Exposures (Food, water, sex, animals, sick people, INSECTS)
  • Prophylaxis, either pretravel or during
  • Illnesses during the trip, and medications
  • Exposures after travel, as not all fevers come from the travel itself
• Performing a thorough physical exam
  • Abdomen for hepatosplenomegaly
  • Eyes for conjunctivitis
  • Lymph nodes
  • Skin for rose spots, maculopapular rashes, petechiae, or purpura
  • Neurologic for AMS
• Specific initial lab tests
  • CBC with manual diff
  • Chemistries and LFTs
  • Pancultures: stool, urine, blood
  • Urinalysis
  • Thin and thick blood smears
• Knowlege of geographic distribution of diseases
  • Dengue and malaria are widespread
  • Plasmodium vivax in the New World, P. falciparum in Africa, and non-P. falciparum in Asia
  • Rickettsia, schistosomiasis, and filariasis in Africa
  • Enteric fevers (typhoid and paratyphoid) are common in South Central Asia
• Knowlege of incubation period for diseases

Sadly, most of the evidence is consensus level or worse, so expect a lot of atypical presentations and results. It does make sense to not just fly off the handle and start ordering West Nile titers on everyone, but instead having a straightforward process to do it. They show this with three case vignettes that are great for adapting into some of your own simulation cases.

One last comment I have is that this paper is open access. That way, everyone can learn that a tourniquet test for dengue involves pumping a blood pressure cuff up to halfway between the patients systolic and diastolic pressure. It’s positive if they’ve got more than 20 petechiae/inch [square inch? -JH].

References

• Feder HM Jr, Mansilla-Rivera K. Fever in returning travelers: a case-based approach. Am Fam Physician. 2013 Oct 15;88(8):524-30. [PMID 24364573]
• Long N. Tropical Travel Trouble. LITFL