Got the Travel Bug? A Review of Common Infections, Infestations, Bites, and Stings Among Returning Travelers

Matthew P. Vasievich; Jose Dario Martinez Villarreal; Kenneth J. Tomecki


Am J Clin Dermatol. 2016;17(5):451-462. 

In This Article

Viral Exanthems


Dengue is an RNA flavivirus that is transmitted from person to person by the Aedes aegypti and Aedes albopictus mosquitos. The shipping industry and air travel have led to both mosquito species now being present throughout the world, though A. aegypti primarily resides in the tropics. The mosquitos can live in forested, rural, and urban areas. They will also enter homes, so travelers are susceptible even if they do not spend significant amounts of time outdoors. Dengue outbreaks have largely been confined to the tropics, though cases have been reported in the Americas. After inoculation of a host by a mosquito bite, the incubation period for the virus averages 4–7 days. Symptoms are somewhat non-specific and include fever, headache, severe myalgias, arthralgias, and gastrointestinal symptoms. Cutaneous manifestations occur in about half of patients and consist of diffuse erythema or a morbilliform rash with islands of sparing (Fig. 8). Petechiae may also be noted on the skin. Diagnosis is by reverse-transcription PCR (RT-PCR) or immunoassays to detect antibody titers against the virus. Treatment is aimed at symptom control, as the disease is usually self-limited and fevers resolve within 2–7 days, though fatigue can persist following infection. Complicated dengue can occur with re-infection in the form of dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS). Mortality rates for DHF or DSS patients are <1 % in centers experienced in treating the disease.[53]

Figure 8.

Morbilliform exanthem with islands of sparing associated with dengue virus infection


Chikungunya virus is an RNA togavirus transmitted by the same Aedes mosquito species as dengue. Outbreaks are again generally confined to the tropics, though cases have been reported in temperate climates such as northern Italy and the mid-western USA. Similar to dengue, the virus incubates for 3–7 days. Symptoms include high fever, symmetric polyarthritis, and gastrointestinal symptoms. Pruritic light pink papules that can progress to bullae occur in 40–50 % of patients 2–5 days after the fever (Fig. 9). The arthritis can be chronic, with more than half of patients reporting joint pain for longer than 18 months. Diagnosis is made by RT-PCR or serologies for IgM or IgG against the virus. Treatment is primarily supportive; non-steroidal anti-inflammatory drugs (NSAIDs) and oral corticosteroids are used for the joint pain associated with the virus.[53]

Figure 9.

Pink- to salmon-colored papules associated with chikungunya virus infection


Zika, like dengue, is an RNA flavivirus transmitted by Aedesaegypti, A. africanus, and A. albopictus mosquitos. The virus was first isolated in Uganda in the late 1940s. Scattered cases had been reported in returning travelers from Africa and Southeast Asia in the late 2000s and early 2010s. The first case in South America was reported in Brazil in 2015, and the virus has spread rapidly since, with cases reported in approximately 29 countries or territories in the Americas as of early 2016. Zika infection is asymptomatic in most cases. Patients who are symptomatic experience mild fever, arthralgias in the small joints of their hands, headache, non-suppurative conjunctivitis, and a morbilliform rash (Fig. 10). Diagnosis is by serum or urine RT-PCR or RT-PCR of amniotic fluid in pregnant women. Complications of Zika virus infection include Guillain–Barré syndrome and microcephaly in the fetus of pregnant women infected in the first trimester. Treatment is again primarily supportive with preventive measures, such as insect repellant and protective clothing, paramount in anyone travelling to areas where they might be exposed to Zika virus.[54]

Figure 10.

Morbilliform exanthem associated with Zika virus infection