Travellers' fever & malaria
Fever in Travellers
- About 50% of fevers are due to tropical disease
- The remainder are due to cosmopolitan illnesses
- The most urgent infections present as febrile illnesses
Travel History
- When did the patient travel?
- Short incubation < 10 days - dengue, malaria, Legionella, cholera, dysentery
- Intermediate 7 - 28 days - Hep A, malaria, typhoid, typhus, amoebic dysentery, TBE, VHF
- Long > 4 weeks - brucellosis, Hep A,B,C,E, Leishmaniasis, malaria, schistosomiasis, rabies
- Weeks - years - HIV, rabies, TB, amoeb
- Duration of travel
- Countries visited
- Type of travel (expatriates, health workers, backpackers, business travellers)
- Insect bites sustained (tsetse, ticks, fleas) anti-malarials taken
- Animal contact
- Swimming in fresh water lakes
Immunisation history
- DTP, polio, Hib, meningitis C
- Hepatitis A/B
- Yellow fever
- Pneumococcal, meningococcal AC, Hib
- Jap B encephalitis, rabies
- TBE (Cholera)
- Anti-malarials taken?
Past Medical History
- Previous and underlying illnesses - IHD, renal/respiratory disease
- Illnesses that may affect immunity
- pregnancy, DM, malignancy, immuno-deficiency, splenectomy, blood disorders (thalassaemia, sickle cell)
Possible localizing symptoms/signs
- Sore throat - streptococcal, diphtheria
- Cough - bronchitis, pneumonia
- Joint pain - pyogenic arthritis
- Loin pain and dysuria - pyelonephritis
- Headache/neck stiffness - meningitis
- Pelvic pain - PID
- Bloody diarrhoea - dysentery
- Skin inflammation - cellulitis, erysipelas
Associated signs and symptoms
- Headache
- Malaria, typhus
- Myalgia
- Dengue, haemorrhagic fevers
- Photophobia
- Rabies, leptospirosis, dengue
- Skin lesions
Type of Fever
- persistent low grade - parasitic, chronic bacterial
- sustained high fever - typhoid, typhus, plague
- subnormal temperatures - protozoan infections, G-ve bacteraemia, overwhelming viral infections
Physical examination
- Must be thorough
- Temperature, pulse, RR, BP
- Jaundice, LNs, rashes, meningism, skin lesions, organomegaly
- If VHF suspected protect yourself!
Types of skin rash
- Papular/maculopapular - spotted fevers, dengue (morbilliform)
- Petechiae/haemorrhagic - usually septicaemias (meningococcal), viral haemorrhagic fevers, dengue (haemorrhagic)
- Scrub typhus
- Rocky Mountain Tick Fever
Localised skin lesions
- Eschars - anthrax, typhus (look for lymphadenopathy)
- Chancre - trypanosomiasis
- Buboes - plague
Causes of Jaundice
- Hepatitis A
- Malaria
- Visceral leishmaniasis
- Viral infections - CMV, EBV
- Typhoid, leptospirosis
- No localizing features
- Septicaemias
- Leptospirosis (often jaundice)
- Tick and louse-borne fevers
Malaria
Important - please se specific page for management of possible malaria here
Other Important Causes of Fever
- Bacterial Infections
- Pneumonia
- UTI
- Streptococcal sore throat
- Typhoid
- Legionella
- Leptospirosis
Enteric Fever
- Salmonella typhi or paratyphi
- Presents with fever, malaise, headache, cough
- After a week ill with splenomegaly and rose spot rash (50%) often paradoxically slow pulse
- WBC usually low, normal platelets
- If delay in treatment complications - bowel perforation, haemorrhage
- Untreated mortality approx 15 %
- Vaccine only 70% efficacy
Legionnaire's Disease
- Causes 4-10 deaths in UK travellers/year
- Often presents non specifically - 'flu' or 'chest infection', has not responded to amoxicillin
- Often confused with hyponatraemia
- Often from common destinations - Spain, Turkey
- CXR most useful. If consolidation - macrolide
Tuberculosis
- May present acutely with fever, cough, night sweats, weight loss
- Abdominal, renal TB may be very difficult to diagnose
- WBC usually normal
Viral Infections
- Dengue and other arbovirus infections
- Hepatitis
- VHF
Dengue Fever
- Fever, headache, retro-orbital pain, severe myalgia, morbilliform rash
- WBC normal or low, thrombocytopaenia
- Haemorrhagic form is uncommon in travellers
- Dengue fever - haemorrhagic
Hepatitis
- Often present as fever
- Fever usually settles when jaundice develops (unlike malaria)
- Normal white cells and platelets
- Raised AST
Viral Haemorrhagic Fevers
- YF, dengue, rift valley fever - mosquitoes
- Crimean-Congo, Omsk, Kyasanur - ticks
- Hantaan, Korean, Lassa - rodent excreta
- Marburg, Ebola - unknown (body fluids)
- Possibility must be considered in febrile travellers
- Incubation 3 - 21 days
Rickettsial and Protozoal Infections
- Tick Typhus
- Louse borne infection
- Amoebic abscess
Chronic fevers
- Need investigations
- FBC and differential often give useful guide
- Possible causes
- Schistosomiasis
- Leishmaniasis, liver flukes, toxocariasis
- Trypanosomiasis
- TB (commonest cause of PUO)
- Plague.
Summary
- Feverish travellers may have potentially fatal illnesses
- Take a thorough travel history
- Check out the VHF page and or use the VHF triage form here (morer informaytion on VF asvailable here)
- Always consider malaria and take 3 thick films
- Give broad spectrum antibiotics if life-threatening infections - meningitis
- Consult early with ID specialists
Links
- British Airways
- Aerospace Medical Association
- UK Foreign Office Medical Travel Advice
- Exodus Ireland - Travel Medicine
- CDC Travellers Health
- UK National Travel Health Network
- TRAVAX
- Health Protection on Malaria
Drafted by Dr John Dallimore, Dr Íomhar O' Sullivan. Published 16/02/2003. Reviewed by Dr ÍOS 03/03/2004, 16/05/2005. Last review Dr. ÍOS 18/01/12
