Evaluation of the Returning Traveler With Fever

A Traveler With Fever

Picture it: Your next patient—either in an emergency room or an outpatient clinic—is a 30-year-old woman who has had 2 days of high fever, headache, and runny nose. While taking her history, you remark on a healing sunburn on her neck. "Oh, I got that in Brazil," she says. "You should've seen it when I first came back a week ago!"

What would you do if this happened tomorrow? What would you have done if this had happened 5 years ago?

Think Zika First

"In somebody coming back [with a fever] from Latin America or the Caribbean, Zika rings all the bells and the flags and the whistles," says Phyllis Kozarsky, MD, a travel medicine expert at the Centers for Disease Control and Prevention (CDC) and professor of infectious diseases at Emory University.

"But if we look at all people who come back with fevers from the tropics, we think about other things," she says. "Things that are common happen commonly."

Zika's explosive spread has resulted in over 3800 travel-associated cases in the United States and US territories combined in 2016. The mass media has covered the epidemic extensively, and with every spike in Zika news coverage, people search for Zika information more frequently online.^[1]

At the same time, front-line physicians in primary care practices and emergency rooms are asking patients about recent travel more now than they did before the Ebola outbreak, says Dr Kozarsky. And when evaluating returning travelers from Latin America and the Caribbean, assessing them for Zika infection often takes top priority.

Zika testing may be indicated in select patients with recent travel to this region (see the CDC's Zika Virus site for up-to-date testing recommendations). However, while evaluating ill returning travelers in the outpatient setting for this relatively new kid on the block, providers shouldn't forget to also assess for the common infections with similar symptoms that have not stopped causing disease in the tropics—even if they're not receiving much press for it.

Beyond Zika: Where to Start

Specialists in infectious disease or tropical medicine may be able to generate an extensive differential diagnosis for a returning traveler's illness based on the patient's history and physical. However, for a primary care or emergency room clinician conducting an initial outpatient evaluation, creating an exhaustive list is not as important as identifying diseases that are rapidly progressive, treatable, transmissible, or all three.

History. The evaluation starts with a careful history. A sample form is available from the CDC. Establish where the patient has traveled or lived and what exposures they had while away. Contact with animals, the outdoors, and untreated water are relevant, as are food and drink, sexual contact with new partners, and a history of insect bites (although because they often go unnoticed, a negative history does not rule them out). Ask about use of any medications or vaccines to prevent disease, as these can reduce the likelihood of certain infections.

Also important is determining when potential exposures took place. The incubation periods of different travel-related infections vary widely, and many diseases can be excluded if a patient becomes ill more than a month after return from travel. This CDC resource is very useful, including a chart delineating common causes of fever, by geographic area.

A history of symptoms should identify gastrointestinal, respiratory, and dermatologic concerns, as well as the peak and duration of any fevers.

Physical examination. The physical exam should include assessment for skin lesions, eye changes, lymphadenopathy, liver or spleen enlargement, neurologic findings, and genital lesions if indicated.

Laboratory tests. Laboratory evaluation should include a complete blood count with differential, a basic chemistry panel, liver function tests, a thick and thin malaria smear, and blood cultures.

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