Fever in the returning child traveller: Highlights for health care providers

Question 1

Which group of people are at highest risk of infection from travelling?

Answer 1

visiting friends and relatives (VFRs)

Because:

• less likely to seek pre-departure advice and more likely to travel for longer periods
• more likely to be exposed to local food, drink, and infectious contacts for longer periods
• often underappreciate the severity of certain endemic infections
• often underappreciate that immunity to malaria wanes over time

Question 2

What are the components of the travel history?

Answer 2

• ask about travel outside of Canada in previous 12 months
• Pre-travel preparation: counselling, vaccinations, malaria chemoprophylaxis, PPE (clothing, insect nets and repellant)
• Travel details and disruptions: destinations, dates, timing of symptom onset
• Setting: rural vs urban, living conditions, altitude, season (ie rainy or dry)
• Activities: VFR or professional, community involvement, environments
• Potential exposures:
  
  • food consumption and handling/preparation (risk for exposure to unpasteurized dairy, meat, seafood)
  • drinking water and fresh water sources (ie for swimming, washing)
  • sick contacts
  • insect bites (esp mosquitos, ticks)
  • animal bites or animal exposures
  • sexual encounters
• Medical care: health care contacts and medication received while travelling and since return

Question 3

What are Host risk factors for travel related illness?

Answer 3

• being unvaccinated or incompletely vaccinated
• hx of compromised or suppressed immunity (splenic dysfunction)
• low wt or poor nutritional status
• young age (<1 mo)

Question 4

What are the travel related organisms that can be asosciated with jaundice?

Answer 4

Question 5

What are the travel related organisms that can be associated with lymph node enlargement?

Answer 5

Question 6

What are the travel related organisms that can be associated with diarrhea?

Answer 6

Question 7

What are the travel related organisms that can be associated with hepatomegaly and splenomegaly?

Answer 7

Question 8

What are the travel related organisms that can be associated with:

• hemorrhagic rash
• fever and rash

Answer 8

Question 9

What are the travel related organisms that can be associated with

• fever and low white count
• fever and eosinophilia

Answer 9

Question 10

What are the travel related organisms that can be associated with fever onset >2 wks and <2 wks?

Answer 10

Question 11

What are the 3 most important DDx for fever in a returning traveller?

Answer 11

1. Malaria (20-30% of cases; onset within 6 mo of return)
2. Travellers diarrhea (10-20%) and enteric fever (2-7%) - onset within 60 days of return
3. Dengue (5%) within 14 days of return

• other infections: chikungunya, zika, viral hemorrhagic fever (Ebola), coronaviruses (Middle East Respiratory Syndrome-CoV)

Question 12

How do you treat a child with suspected P falciparum?

Answer 12

• all children and youth with suspected P falciparum should be admitted to hospital and treated for chloroquine-resistant malaria until speciation available
• urgent consult with ID expert
• artesunate or quinine

mortality rate 20% for plasmodium falciparum

Question 13

What does the lab work of someone with Typhoid fever show?

Answer 13

leukopenia and thrombocytopenia

BCx is important for diagnosis (more than one sample may be required)

Question 14

What are the etiologies for traveller’s diarrhea in:

acute < 2 wks

chronic > 2 wks

Answer 14

acute (<2 weeks): rotavirus or bacterial

chronic (> 2 weeks): post-infectious diarrhea, giardiasis

Tx: Antibiotics if stools are bloody

Question 15

What is caused by mosquitoes that bite at night vs in the day?

Answer 15

day: dengue
night: malaria

Question 16

Dengue fever:

What can repeat infections present as?

What does labwork show?

Management?

Answer 16

Repeat infections can present as: hemorrhagic dengue or as shock syndrome (with hypoNa, hypoproteinemia, circulatory collapse)

Labwork: lymphocytosis, neutropenia, elevated aminotransferases

Management:

• supportive, rest, fluids, antipyretics, analgesia, transfusion
• rule out sepsis and malaria
• avoid NSAIDs, steroids due to bleeding risk

Question 17

What medications do you need to avoid in Dengue?

Answer 17

avoid NSAIDs, steroids due to bleeding risk

Question 18

What investigations should you do for returning traveller with fever?

Answer 18

• CBC with diff, LET, lytes, Cr
• malaria smears +/- antigen detection testing when available
  
  • (at least 2 subsequent samples over 24-48 hours when child has visited a malaria-endemic area)
• Blood Cx
• UA +/- UCx

Consider:

• stool culture for enteropathogens (YSSEC)
• CXR
• Stool for O&P (chronic diarrhea or immunocompromised) - cyclospora, cryptosporidium, E histolytica, giardia
• Viral serology: acute and convalescent serology should be saved and run if no dx within 10-14 days
  
  • dengue if fever onset within 14 days from S Asia, SE Asia, Latin America, or caribbean
  • Chikungunya serology: SEA, Latin America, Caribbean
  • Zika or arboviruses

Question 19

How would you manage an unwell appearing traveller with fever?

Answer 19

Think about P. falciparum!

1. empirically tx for P falciparum malaria if child unwell or lab diagnosis may be delayed, including broad spectrum abx with G- coverage
2. Remember: malaria can present as co-infection with pneumonia or bacteremia

Question 20

What is the incubation period of the DDx for fever in returning traveller?

Answer 20

• Malaria: onset within 6 mo of return
• Travellers diarrhea and enteric fever - within 60 days of return
• Dengue - within 14 days of return