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

table

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].

Fever in Returning Travelers: A Case-Based Approach
http://www.aafp.org/afp/2013/1015/p524.html

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