Chapter 117. Health Advice for International Travel (Part 9)

Fever Fever in a traveler who has returned from a malarious area should be considered a medical emergency because death from P. falciparum malaria can follow an illness of only several days duration. Although "fever from the tropics" does not always have a tropical cause, malaria should be the first diagnosis considered. The risk of P. falciparum malaria is highest among travelers returning from Africa or Oceania and among those who become symptomatic within the first 2 months after return. Other important causes of fever after travel include viral hepatitis (hepatitis A and E), typhoid fever, bacterial enteritis, arboviral...
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Chapter 117. Health Advice for International Travel (Part 9) Chapter 117. Health Advice for International Travel (Part 9) Fever Fever in a traveler who has returned from a malarious area should beconsidered a medical emergency because death from P. falciparum malaria canfollow an illness of only several days duration. Although fever from the tropicsdoes not always have a tropical cause, malaria should be the first diagnosisconsidered. The risk of P. falciparum malaria is highest among travelers returningfrom Africa or Oceania and among those who become symptomatic within thefirst 2 months after return. Other important causes of fever after travel includeviral hepatitis (hepatitis A and E), typhoid fever, bacterial enteritis, arboviralinfections (e.g., dengue fever), rickettsial infections (including tick and scrubtyphus and Q fever), and—in rare instances—leptospirosis, acute HIV infection,and amebic liver abscess. A cooperative study by GeoSentinel (an emerginginfectious disease surveillance group established by the CDC and the InternationalSociety of Travel Medicine) showed that, among 3907 febrile returned travelers,malaria was acquired most often from Africa, dengue from Southeast Asia and theCaribbean, typhoid fever from southern Asia, and rickettsial infections (ticktyphus) from southern Africa (Table 117-3). In at least 25% of cases, no etiologycan be found, and the illness resolves spontaneously. Clinicians should keep inmind that no present-day antimalarial agent guarantees protection from malariaand that some immunizations (notably, that against typhoid fever) are onlypartially protective. Table 117-3 Etiology and Geographic Distribution (Percent) ofSystemic Febrile Illness in Returned Travelers (N = 3907) Etiology Car CA SA SS S SE ib m m A CA A Malaria Mononucle 7 7 8 1 2 3osis Rickettsia 0 0 0 6 1 2 Salmonella 2 3 2 Skin Diseases Pyodermas, sunburn, insect bites, skin ulcers, and cutaneous larva migransare the most common skin conditions affecting travelers after their return home. Inthose with persistent skin ulcers, a diagnosis of cutaneous leishmaniasis,mycobacterial infection, or fungal infection should be considered. Careful,complete inspection of the skin is important in detecting the rickettsial eschar in afebrile patient or the central breathing hole in a boil due to myiasis. Emerging Infectious Diseases In recent years, travel and commerce have fostered the worldwide spread ofHIV infection, led to the reemergence of cholera as a global health threat, andcreated considerable fear about the possible spread of severe acute respiratorysyndrome (SARS) and avian influenza (H5N1). For travelers, there are morerealistic concerns. One of the largest outbreaks of dengue fever ever documentedis now raging in Latin America; schistosomiasis is being described in previouslyunaffected lakes in Africa; and antibiotic-resistant strains of sexually transmittedand enteric pathogens are emerging at an alarming rate in the developing world. Inaddition, concerns have been raised about the potential for bioterrorism involvingnot only standard strains of unusual agents but mutant strains as well. Time willtell whether travelers (as well as persons at home) will routinely be vaccinatedagainst diseases such as anthrax and smallpox. As Nobel laureate Dr. JoshuaLederberg pointed out, The microbe that felled one child in a distant continentyesterday can reach yours today and seed a global pandemic tomorrow. Thevigilant clinician understands that the importance of a thorough travel historycannot be overemphasized. Further Readings Chen LH, Keystone JS: New strategies for the prevention of malaria intravelers. Infect Dis Clin North Am 19:185, 2005 [PMID: 16027794] DuPont AW, DuPont HL: Travelers diarrhea: Modern concepts and newdevelopments. Curr Treat Options Gastroenterol 9:13, 2006 [PMID: 16423310] Freedman DO et al (GeoSentinel Surveillance Network): Spectrum ofdisease and relation to place of exposure among ill returned travelers. N Engl JMed 354:119, 2006 [PMID: 16407507] Keystone JS et al: Travel Medicine. Mosby, Philadelphia, 2004 Okhuysen PC: Current concepts in travelers diarrhea: Epidemiology,antimicrobial resistance and treatment. Curr Opin Infect Dis 18:522, 2005 [PMID:16258326] Ryan ET et al: Illness after international travel. N Engl J Med 347:505,2002 [PMID: 12181406] Shlim DR: Update in travelers diarrhea. Infect Dis Clin North Am 19:137,2005 [PMID: 15701551] Sohail MR, Fischer PR: Health risks to air travelers. Infect Dis Clin NorthAm 19:67, 2005 [PMID: 15701547] Wilson ME, Chen LH: Dermatologic infectious diseases in internationaltravelers. Curr Infect Dis Rep 6:54, 2004 [PMID: 14733850] Websites of Interest: Chronic renal failure: www.kidney.org. Diabetes:www.diabetesmonitor.com/other-14.htm. Dialysis: www.dialysisfinder.com.Disability: www.access-able.com. HIV: www.aegis.com Bibliography Angell SY, Behrens RH: Risk assessment and disease prevention intravelers visiting friends and relatives. Infect Dis Clin North Am 19:49, 2005[PMID: 15701546] Caumes E et al: Dermatoses associated with travel to tropical countries: Aprospective study of the diagnosis and management of 269 patients presenting to atropical disease unit. Clin Infect Dis 20:542, 1995 [PMID: 7756473] ...