Chapter 117. Health Advice for International Travel (Part 9) pptx

Chapter 117. Health Advice for
International Travel
(Part 9)

Fever
Fever in a traveler who has returned from a malarious area should be
considered a medical emergency because death from P. falciparum malaria can
follow an illness of only several days' duration. Although "fever from the tropics"
does not always have a tropical cause, malaria should be the first diagnosis
considered. The risk of P. falciparum malaria is highest among travelers returning
from Africa or Oceania and among those who become symptomatic within the
first 2 months after return. Other important causes of fever after travel include
viral hepatitis (hepatitis A and E), typhoid fever, bacterial enteritis, arboviral
infections (e.g., dengue fever), rickettsial infections (including tick and scrub
typhus and Q fever), and—in rare instances—leptospirosis, acute HIV infection,
and amebic liver abscess. A cooperative study by GeoSentinel (an emerging
infectious disease surveillance group established by the CDC and the International
Society of Travel Medicine) showed that, among 3907 febrile returned travelers,
malaria was acquired most often from Africa, dengue from Southeast Asia and the
Caribbean, typhoid fever from southern Asia, and rickettsial infections (tick
typhus) from southern Africa (Table 117-3). In at least 25% of cases, no etiology
can be found, and the illness resolves spontaneously. Clinicians should keep in
mind that no present-day antimalarial agent guarantees protection from malaria
and that some immunizations (notably, that against typhoid fever) are only
partially protective.
Table 117-
3 Etiology and Geographic Distribution (Percent) of
Systemic Febrile Illness in Returned Travelers (N = 3907)

Etiology Car
ib

CA
m
SA
m
SS
A
S
CA
SE
A
Malaria <1 13 13

62

14

13

Dengue 23 12 14

<1

14

32

Mononucle
osis
7 7 8 1 2 3
Rickettsia 0 0 0 6

1 2
Salmonella

2 3 2 <1

14

3

Note: Carib, Caribbean; CAm, Central America; SAm, South America;
SSA, Sub-Saharan Africa; SCA, South Central Asia; SEA, Southeast Asia. Bold
type is for emphasis only.
Source: Revised from Table 2 in Freedman et al, 2006. Used with
permission from the Massachusetts Medical Society.
When no specific diagnosis is forthcoming, the following investigations,
where applicable, are suggested: complete blood count, liver function tests,
thick/thin blood films for malaria (repeated twice if necessary), urinalysis, urine
and blood cultures (repeated once), chest x-ray, and collection of an acute-phase
serum sample to be held for subsequent examination along with a paired
convalescent-phase serum sample.
Skin Diseases
Pyodermas, sunburn, insect bites, skin ulcers, and cutaneous larva migrans
are the most common skin conditions affecting travelers after their return home. In
those with persistent skin ulcers, a diagnosis of cutaneous leishmaniasis,
mycobacterial infection, or fungal infection should be considered. Careful,
complete inspection of the skin is important in detecting the rickettsial eschar in a
febrile patient or the central breathing hole in a "boil" due to myiasis.
Emerging Infectious Diseases
In recent years, travel and commerce have fostered the worldwide spread of

HIV infection, led to the reemergence of cholera as a global health threat, and
created considerable fear about the possible spread of severe acute respiratory
syndrome (SARS) and avian influenza (H5N1). For travelers, there are more
realistic concerns. One of the largest outbreaks of dengue fever ever documented
is now raging in Latin America; schistosomiasis is being described in previously
unaffected lakes in Africa; and antibiotic-resistant strains of sexually transmitted
and enteric pathogens are emerging at an alarming rate in the developing world. In
addition, concerns have been raised about the potential for bioterrorism involving
not only standard strains of unusual agents but mutant strains as well. Time will
tell whether travelers (as well as persons at home) will routinely be vaccinated
against diseases such as anthrax and smallpox. As Nobel laureate Dr. Joshua
Lederberg pointed out, "The microbe that felled one child in a distant continent
yesterday can reach yours today and seed a global pandemic tomorrow." The
vigilant clinician understands that the importance of a thorough travel history
cannot be overemphasized.
Further Readings
Chen LH,
Keystone JS: New strategies for the prevention of malaria in
travelers. Infect Dis Clin North Am 19:185, 2005 [PMID: 16027794]
DuPont AW, DuPont HL: Travelers' diarrhea: Modern concepts and new
developments. Curr Treat Options Gastroenterol 9:13, 2006 [PMID: 16423310]
Freedman DO et al (GeoSentinel Surveillance Network): Spectrum of
disease and relation to place of exposure among ill returned travelers. N Engl J
Med 354:119, 2006 [PMID: 16407507]
Keystone JS et al: Travel Medicine. Mosby, Philadelphia, 2004
Okhuysen PC: Current concepts in travelers' diarrhea: Epidemiology,
antimicrobial resistance and treatment. Curr Opin Infect Dis 18:522, 2005 [PMID:
16258326]
Ryan ET et al: Illness after international travel. N Engl J Med 347:505,
2002 [PMID: 12181406]

Shlim DR: Update in traveler's diarrhea. Infect Dis Clin North Am 19:137,
2005 [PMID: 15701551]
Sohail MR, Fischer PR: Health risks to air travelers. Infect Dis Clin North
Am 19:67, 2005 [PMID: 15701547]
Wilson ME, Chen LH: Dermatologic infe
ctious diseases in international
travelers. Curr Infect Dis Rep 6:54, 2004 [PMID: 14733850]
Websites of Interest: Chronic renal failure: www.kidney.org
. Diabetes:
www.diabetesmonitor.com/other-14.htm. Dialysis: www.dialysisfinder.com
.
Disability: www.access-able.com. HIV: www.aegis.com
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