Fever in traveler: Difference between revisions

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=General=
==Background==
*If incubation period >1 month: dengue, rickettsia, viral hemorrhagic fever less likely
*If incubation period >1 month: dengue, rickettsia, viral hemorrhagic fever less likely
*CBC with differential; thick smear; liver function tests; urinalysis; blood & stool cultures; chest x-ray; serologies for specific viruses


=Differential Diagnosis=
==Clinical Features==
*[[Malaria]]
*[[Fever]] and exposure outside of U.S.
*[[Dengue]]
*[[Leptospirosis]]
*[[Typhoid Fever]]
*[[Typhus]]
*[[Hemorrhagic Fevers]]


=Fever + CNS Changes=
==Differential Diagnosis==
*malaria, tuberculosis, typhoid fever, rickettsia, poliomyelitis, rabies, viral (Japanese/ West Nile/ tick borne) encephalitis
{{Template:Fever in Traveler DDX}}
*meningococcal meningitis associated with Haj to Mecca
*eosinophilic meningitis associated with coccidiomycosis or angiostrongyliasis (rat lung worm to brain)
*trypanosomiasis by tsetse fly = Africal sleeping sickness = red chancre at site of fly bite, fever, headache, myalgias proceding to meningoencephalitis. May see trypansosomes in smear in acute phase


=Fever + Respiratory Symptoms=
===Fever with CNS Changes===
*streptococcal pneumonia, influenza, mycoplasma, legionella, tuberculosis
*[[Malaria]],
*Q fever: ''coxiella burnetti'': fever, pneumonia, hepatitis after animal exposure
*[[Tuberculosis]]
*Loffler's syndrome: pulmonary infiltrates, eosinophilia from transient migration of larval helminthes through lungs
*[[Typhoid fever]]
*cough also seen in malaria, typhoid fever, scrub typhus, dengue
*[[Rickettsia]]
*[[Poliomyelitis]]
*[[Rabies]]
*Viral (Japanese/ West Nile/ tick borne) encephalitis
*Meningococcal meningitis (associated with Haj to Mecca)
*Eosinophilic meningitis
**Associated with coccidiomycosis or angiostrongyliasis (rat lung worm to brain)
*[[Trypanosomiasis]] (African sleeping sickness)


=Sexually Transmitted / Blood Exposure and Fever=
===Fever and Respiratory Symptoms===
*can have fever without genital findings: HIV, syphilis (''Treponema pallidum'') cytomegalovirus (CMV), Epstein-Barr Virus (EBV), hepatitis B
*[[Pneumonia]]
*also from tattoos, piercings, share razor, blood transfusion
*[[Influenza]]
*[[Mycoplasma]]
*[[Legionella]]
*[[Tuberculosis]]
*[[Q fever]] ''coxiella burnetti''
*[[Loffler's syndrome]]


=See Also=
===Fever with Sexual/Blood Exposure===
[[Travel Medicine]]
*[[HIV]]
*[[Syphilis]] (''Treponema pallidum'')
*[[Cytomegalovirus]] (CMV)
*[[Epstein-Barr virus]] (EBV)
*[[Hepatitis B]]
**[[Hepatitis D]] co-infection


==Evaluation==
===Workup===
'''Always consider malaria'''
*Malaria smear (thick and thin)
*CBC with differential
*Chemistry panel
*Liver function tests
*Blood culture
*[[Urinalysis]] and urine culture
*Stool culture
*Chest x-ray
*Additional to consider:
**[[Lumbar puncture]]
**[[Viral hepatitis|Hepatitis]] panel
**[[STD]] studies
**Serologies for specific viruses
**Other radiography (CT scan, abdominal ultrasound, MRI brain)
===Diagnosis===
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''GEOGRAPHIC AREA'''
| align="center" style="background:#f0f0f0;"|'''COMMON TROPICAL DISEASE CAUSING FEVER'''
| align="center" style="background:#f0f0f0;"|'''OTHER INFECTIONS CAUSING OUTBREAKS OR CLUSTERS IN TRAVELERS'''
|-
| Caribbean||[[Dengue]], [[malaria]] (Haiti)||Acute [[histoplasmosis]], [[leptospirosis]], [[chikungunya]]
|-
| Central America||[[Dengue]], [[malaria]] (primarily Plasmodium vivax)||[[Leptospirosis]], [[histoplasmosis]], [[coccidioidomycosis]]
|-
| South America||[[Dengue]], [[malaria]] (primarily P. vivax)||[[Bartonellosis]], [[leptospirosis]], [[enteric fever]], [[histoplasmosis]]
|-
| South-central Asia||[[Dengue]], [[enteric fever]], [[malaria]] (primarily non-falciparum)||[[Chikungunya]]
|-
| Southeast Asia||[[Dengue]], [[malaria]] (primarily non-falciparum)||[[Chikungunya]], [[leptospirosis]]
|-
| Sub-Saharan Africa||[[Malaria]] (primarily P. falciparum), tickborne [[rickettsiae]] (main cause of fever in southern Africa), acute [[schistosomiasis]], [[filariasis]]||[[African trypanosomiasis]], [[chikungunya]], [[enteric fever]], [[filariasis]]
|}
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''DISEASE'''
| align="center" style="background:#f0f0f0;"|'''USUAL INCUBATION PERIOD (RANGE)'''
| align="center" style="background:#f0f0f0;"|'''DISTRIBUTION'''
|-
| '''Incubation <14 days'''||||
|-
| [[Chikungunya]]||2–4 days (1–14 days)||Tropics, subtropics
|-
| [[Dengue]]||4–8 days (3–14 days)||Topics, subtropics
|-
| Encephalitis, arboviral ([[Japanese encephalitis]], [[tickborne encephalitis]], [[West Nile virus]], other)||3–14 days (1–20 days)||Specific agents vary by region
|-
| [[Enteric fever]]||7–18 days (3–60 days)||Especially in Indian subcontinent
|-
| [[Acute HIV]]||10–28 days (10 days to 6 weeks)||Worldwide
|-
| [[Influenza]]||1–3 days||Worldwide, can also be acquired while traveling
|-
| [[Legionellosis]]||5–6 days (2–10 days)||Widespread
|-
| [[Leptospirosis]]||7–12 days (2–26 days)||Widespread, most common in tropical areas
|-
| [[Malaria]], Plasmodium falciparum||6–30 days (98% onset within 3 months of travel)||Tropics, subtropics
|-
| [[Malaria]], P. vivax||8 days to 12 months (almost half have onset >30 days after completion of travel)||Widespread in tropics and subtropics
|-
| [[Spotted-fever rickettsiae]]||Few days to 2–3 weeks||Causative species vary by region
|-
| '''Incubation 14 Days to 6 Weeks'''||||
|-
| [[Encephalitis]], [[arboviral]]; [[enteric fever]]; acute [[HIV]]; [[leptospirosis]]; [[malaria]]||See above incubation periods for relevant diseases||See above distribution for relevant diseases
|-
| [[Amebic liver abscess]]||Weeks to months||Most common in developing countries
|-
| [[Hepatitis A]]||28–30 days (15–50 days)||Most common in developing countries
|-
| [[Hepatitis E]]||26–42 days (2–9 weeks)||Widespread
|-
| Acute [[schistosomiasis]] (Katayama syndrome)||4–8 weeks||Most common in sub-Saharan Africa
|-
| '''Incubation >6 weeks'''||||
|-
| [[Amebic liver abscess]], hepatitis E, malaria, acute schistosomiasis||See above incubation periods for relevant diseases||See above distribution for relevant diseases
|-
| [[Hepatitis B]]||90 days (60–150 days)||Widespread
|-
| [[Leishmaniasis]], visceral||2–10 months (10 days to years)||Asia, Africa, Latin America, southern Europe, and the Middle East
|-
| [[Tuberculosis]]||Primary, weeks; reactivation, years||Global distribution, rates and levels of resistance vary widely
|}
==Management==
==Disposition==
==See Also==
*[[Travel Medicine]]
==External Links==
*https://wwwnc.cdc.gov/travel/yellowbook/2016/post-travel-evaluation/fever-in-returned-travelers
*https://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=167&seg_id=3279
==References==
<references/>
[[Category:ID]]
[[Category:ID]]
[[Category:TropMed]]
[[Category:Tropical Medicine]]

Latest revision as of 14:53, 18 August 2019

Background

  • If incubation period >1 month: dengue, rickettsia, viral hemorrhagic fever less likely

Clinical Features

  • Fever and exposure outside of U.S.

Differential Diagnosis

Fever in traveler

Fever with CNS Changes

Fever and Respiratory Symptoms

Fever with Sexual/Blood Exposure

Evaluation

Workup

Always consider malaria

  • Malaria smear (thick and thin)
  • CBC with differential
  • Chemistry panel
  • Liver function tests
  • Blood culture
  • Urinalysis and urine culture
  • Stool culture
  • Chest x-ray
  • Additional to consider:
    • Lumbar puncture
    • Hepatitis panel
    • STD studies
    • Serologies for specific viruses
    • Other radiography (CT scan, abdominal ultrasound, MRI brain)

Diagnosis

GEOGRAPHIC AREA COMMON TROPICAL DISEASE CAUSING FEVER OTHER INFECTIONS CAUSING OUTBREAKS OR CLUSTERS IN TRAVELERS
Caribbean Dengue, malaria (Haiti) Acute histoplasmosis, leptospirosis, chikungunya
Central America Dengue, malaria (primarily Plasmodium vivax) Leptospirosis, histoplasmosis, coccidioidomycosis
South America Dengue, malaria (primarily P. vivax) Bartonellosis, leptospirosis, enteric fever, histoplasmosis
South-central Asia Dengue, enteric fever, malaria (primarily non-falciparum) Chikungunya
Southeast Asia Dengue, malaria (primarily non-falciparum) Chikungunya, leptospirosis
Sub-Saharan Africa Malaria (primarily P. falciparum), tickborne rickettsiae (main cause of fever in southern Africa), acute schistosomiasis, filariasis African trypanosomiasis, chikungunya, enteric fever, filariasis
DISEASE USUAL INCUBATION PERIOD (RANGE) DISTRIBUTION
Incubation <14 days
Chikungunya 2–4 days (1–14 days) Tropics, subtropics
Dengue 4–8 days (3–14 days) Topics, subtropics
Encephalitis, arboviral (Japanese encephalitis, tickborne encephalitis, West Nile virus, other) 3–14 days (1–20 days) Specific agents vary by region
Enteric fever 7–18 days (3–60 days) Especially in Indian subcontinent
Acute HIV 10–28 days (10 days to 6 weeks) Worldwide
Influenza 1–3 days Worldwide, can also be acquired while traveling
Legionellosis 5–6 days (2–10 days) Widespread
Leptospirosis 7–12 days (2–26 days) Widespread, most common in tropical areas
Malaria, Plasmodium falciparum 6–30 days (98% onset within 3 months of travel) Tropics, subtropics
Malaria, P. vivax 8 days to 12 months (almost half have onset >30 days after completion of travel) Widespread in tropics and subtropics
Spotted-fever rickettsiae Few days to 2–3 weeks Causative species vary by region
Incubation 14 Days to 6 Weeks
Encephalitis, arboviral; enteric fever; acute HIV; leptospirosis; malaria See above incubation periods for relevant diseases See above distribution for relevant diseases
Amebic liver abscess Weeks to months Most common in developing countries
Hepatitis A 28–30 days (15–50 days) Most common in developing countries
Hepatitis E 26–42 days (2–9 weeks) Widespread
Acute schistosomiasis (Katayama syndrome) 4–8 weeks Most common in sub-Saharan Africa
Incubation >6 weeks
Amebic liver abscess, hepatitis E, malaria, acute schistosomiasis See above incubation periods for relevant diseases See above distribution for relevant diseases
Hepatitis B 90 days (60–150 days) Widespread
Leishmaniasis, visceral 2–10 months (10 days to years) Asia, Africa, Latin America, southern Europe, and the Middle East
Tuberculosis Primary, weeks; reactivation, years Global distribution, rates and levels of resistance vary widely

Management

Disposition

See Also

External Links

References

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