Approach to the International Traveler With Neurological Symptoms

Kiran T Thakur; Joseph R Zunt

Disclosures

Future Neurology. 2015;10(2):101-113. 

In This Article

General Approach to Returning Traveler

A thorough post-travel evaluation is essential for establishing the diagnosis and treatment plan for a patient. Resources that can be utilized to aide in diagnosis and management include local and state-run travel clinics and the CDC, which provides up-to-date information regarding travel-related illnesses.[9] In the initial assessment, the clinician should identify and rule out potential life-threatening etiologies. History should be obtained from the patient as well as from fellow accompanying travelers and a thorough investigation should be performed; any presumptive therapy should be guided by conditions endemic to the region through which the patient traveled. Important historical questions to ask include travel dates, countries visited – including stopovers, destinations within the countries (rural or urban), climatic and living conditions (e.g., staying outdoors or in a crowded living facility), exposures to bites, animals, ill people, sexual history including unprotected intercourse, types of food and liquids consumed (including cooking preparation), vaccination and medication prophylaxis history, type of travel (e.g., backpacking, group-travel, luxury), quality of travel (e.g., long periods of sleep deprivation), medications taken on the trip, injuries or illnesses during the trip and a detailed assessment of the timing and sequence of symptoms (Box 1). Illnesses acquired while traveling typically manifest within 1 month after returning to the country of origin, although some conditions may have longer incubation periods and clinicians should be aware that remote exposures could influence the patient's current health status (Table 2). Information regarding the type, location and progression of neurological symptoms and assessment of systemic symptoms should be collected in detail.

During the initial physical examination, severity of illness should be assessed. If signs of serious illness are present, the patient should be promptly hospitalized for evaluation and treatment. Assessment of all returning travelers should include measurement of vital signs, examination of the skin for rash or bites and of the lymph nodes for swelling; auscultation of the heart and lungs; and palpation of the abdomen, with assessment of the size of the liver and spleen. Certain findings on general physical examination may provide clues to the underlying etiology of neurological symptoms. For example, the finding of a black necrotic ulcer with erythematous margins (an eschar) may suggest rickettsial disease (Table 3). A complete neurological examination should be performed on all patients. Evaluation of the comatose patient should pay special attention to signs that could assist with localization of dysfunction within the nervous system, including the ophthalmologic and cranial nerve examinations, assessment for posturing and measurement of the Glasgow Coma Scale (GCS) – all of which should be closely monitored throughout the patient's hospitalization.

Laboratory evaluation should be guided by the differential diagnosis developed from the patient's history and physical examination, with particular emphasis on the patient's travel itinerary, exposure history and endemic diseases present in the countries visited by the patient. Initial laboratory evaluation should include complete blood count (CBC), complete metabolic panel including liver function tests (LFTs), urinalysis and blood cultures. Thick and thin blood films for malaria should be performed in all febrile patients who have traveled through malaria-endemic regions. If the patient is confused or displays signs of meningismus, imaging studies and lumbar puncture (LP) should be performed. MRI is preferred over CT scan when available, as MRI provides more detailed structural analysis. Electroencephalogram (EEG) and nerve conduction studies/electromyography (NCS/EMG) should be considered if seizures or neuromuscular dysfunction is suspected. Evaluation for specific neurological symptoms will be discussed in later sections. Consultation with experts in travel medicine or physicians who practice in the country of travel can provide valuable guidance regarding endemic diseases as well as any disease outbreaks at the time of the patient's travel. If the patient has a condition that is potentially contagious, all contacts during travel should be promptly contacted and governmental agencies should be involved for further assistance.

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