Evaluation of fever in the returning traveler
- Mary Elizabeth Wilson, MD
Mary Elizabeth Wilson, MD
- Clinical Professor of Epidemiology and Biostatistics
- School of Medicine, University of California, San Francisco
- Adjunct Professor of Global Health and Population
- Harvard TH Chan School of Public Health
The evaluation of fever in returned travelers should focus on the possible infections given the patient's clinical findings, travel geography, administration (if any) of vaccinations and malaria chemoprophylaxis, the nature and timeframe of potential exposure(s), and the incubation period(s) of the relevant possible infections (table 1) .
Good resources that provide current information about the infections that occur in various geographic areas are essential [2-4]. The United States Centers for Disease Control and Prevention website includes an online version of Health Information for International Travel under Travelers' Health and updates on travel-related infections . The World Health Organization website also has regularly updated information about outbreaks.
The approach to evaluation of fever in the returning traveler will be reviewed here. Other issues related to travel are discussed separately:
●(See "Travel advice".)
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- Thwaites GE, Day NP. Approach to Fever in the Returning Traveler. N Engl J Med 2017; 376:548.
- World Health Organization. International Travel and Health: Vaccination Requirements and Health Advice, Geneva: World Health Organization (Updated and published annually).
- Wilson ME. A world guide to infections: Diseases, distribution, diagnosis, Oxford University Press, New York 1991.
- Centers for Disease Control and Prevention. Health Information for International Travel 2018: The Yellow Book. https://wwwnc.cdc.gov/travel/page/yellowbook-home (Accessed on June 20, 2017).
- 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; 354:119.
- Wilson ME, Weld LH, Boggild A, et al. Fever in returned travelers: results from the GeoSentinel Surveillance Network. Clin Infect Dis 2007; 44:1560.
- Bottieau E, Clerinx J, Schrooten W, et al. Etiology and outcome of fever after a stay in the tropics. Arch Intern Med 2006; 166:1642.
- Harvey K, Esposito DH, Han P, et al. Surveillance for travel-related disease--GeoSentinel Surveillance System, United States, 1997-2011. MMWR Surveill Summ 2013; 62:1.
- Leder K, Torresi J, Libman MD, et al. GeoSentinel surveillance of illness in returned travelers, 2007-2011. Ann Intern Med 2013; 158:456.
- Jensenius M, Han PV, Schlagenhauf P, et al. Acute and potentially life-threatening tropical diseases in western travelers--a GeoSentinel multicenter study, 1996-2011. Am J Trop Med Hyg 2013; 88:397.
- Ryan ET, Wilson ME, Kain KC. Illness after international travel. N Engl J Med 2002; 347:505.
- Dorsey G, Gandhi M, Oyugi JH, Rosenthal PJ. Difficulties in the prevention, diagnosis, and treatment of imported malaria. Arch Intern Med 2000; 160:2505.
- Newman RD, Parise ME, Barber AM, Steketee RW. Malaria-related deaths among U.S. travelers, 1963-2001. Ann Intern Med 2004; 141:547.
- Christen D, Steffen R, Schlagenhauf P. Deaths caused by malaria in Switzerland 1988-2002. Am J Trop Med Hyg 2006; 75:1188.
- Chen LH, Wilson ME, Schlagenhauf P. Controversies and misconceptions in malaria chemoprophylaxis for travelers. JAMA 2007; 297:2251.
- Reyburn H, Behrens RH, Warhurst D, Bradley D. The effect of chemoprophylaxis on the timing of onset of falciparum malaria. Trop Med Int Health 1998; 3:281.
- Petersen LR, Jamieson DJ, Powers AM, Honein MA. Zika Virus. N Engl J Med 2016; 374:1552.
- Matteelli A, Carosi G. Sexually transmitted diseases in travelers. Clin Infect Dis 2001; 32:1063.
- Rogstad KE. Sex, sun, sea, and STIs: sexually transmitted infections acquired on holiday. BMJ 2004; 329:214.
- EPIDEMIOLOGY AND ETIOLOGY
- INITIAL EVALUATION
- History and physical examination
- Laboratory tests
- SUBSEQUENT CLINICAL APPROACH
- Evaluate for malaria
- Consider the presenting syndrome
- - Fever with respiratory symptoms
- Absence of eosinophilia
- Presence of eosinophilia
- - Fever with jaundice
- - Fever with abdominal pain
- - Fever with diarrhea
- Diarrhea in absence of fever
- - Fever with rash
- - Fever with neurologic symptoms
- - Fever with no localizing symptoms
- Incubation period ≤10 days
- Incubation period >10 days
- Consider the incubation period
- Consider the exposure history
- - Unclean water or undercooked food
- - Arthropod bites
- - Animal exposures
- - Sexual contact
- Consider the geographic region(s) of exposure
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS