Returning traveler with fever and diarrhea

Classic Travelers’ diarrhea is not associated with fever, or if any, is usually low grade. It is typically seen during one’s travel, away from home, and is caused by Enterotoxigenic/Enteroaggregative Escherichia Coli, toxins and viruses.

However, nearly 10-20% of returning travelers presenting for evaluation of fever have associated diarrhea. Diarrhea is defined as 3 or more non-formed stools in a 24 hour period. In addition one also commonly sees symptoms of bloody stools and tenesmus (painful defecation with a feeling that you still have to go).

Common pathogens responsible for fever and diarrhea are described below. 

Symptoms occurring within two weeks of travel:

  • Bacteria: Shigella, Salmonella typhi, Salmonella paratyphi and Campylobacter. Rarely other bacteria like Enteroinvasive or Enterohemmorrhagic Escherichia Coli, Plesiomonas, Aeromonas, Vibrio Parahemolyticus and Clostridium Difficile can also cause illness.
  • Parasites: Rarely cause symptoms within two weeks, usually takes 2-4 weeks or more.

Symptoms occurring more than two weeks, usually 4-6 after travel:

  • Parasites: Entamoeba histolytica is typically associated with fever, bloody stools and diarrhea. Giardia lamblia while causing diarrhea does not typically have fever, but is associated with belching, bloating, indigestion and abdominal cramps.

Returning traveler with fever and hemorrhagic symptoms

A traveler who returns from an exotic far away country with high fever and blood oozing from every orifice or worse from intact skin is everyone’s worst nightmare of travel and the stuff of movies. Fortunately this scenario is mostly the stuff of movies.

However, there are a few common infectious diseases that in extremely severe cases could potentially present this way. There are also some uncommon diseases that theoretically could occur in travelers and present this way.

Patients can present with bleeding from the gums, nose, eyes, gastrointestinal system or blotchy to sand paper like red rash on the skin.

Common pathogens responsible for fever and hemorrhagic symptoms are described below:

Symptoms occurring within two weeks of travel:

  • Bacteria: Meningococcus, malaria, leptospira and rickettsia infections can progress to extremely severe states resulting in hemorrhage. This usually happens when medical therapy is not readily available and symptoms have continually progressed.

Symptoms occurring more than two weeks after travel:

  • Viruses: Ebola, Lassa, Marburg, Yellow Fever, Rift Valley, Hanta, Crimean-Congo, Dengue.

Returning traveler with fever and neurologic symptoms

Neurologic symptoms are fortunately very rare in returning travelers but can be caused by a variety of pathogens including bacteria, viruses, fungi and parasites.

Common presenting symptoms include confusion, hallucination, drowsiness, focal weakness of limb or facial muscles and stiffness of neck.
Common pathogens responsible for fever and neurologic symptoms are described below:

Symptoms occurring within two weeks of travel:

  • Viruses: Japanese encephalitis virus, West Nile virus, Tick Borne Encephalitis virus, Equine Encephalitis viruses, Polio virus, Rabies virus etc
  • Bacteria: Neisseria meningitides especially if one has traveled to the Sub-Saharan meningitis belt of Africa or the hajj pilgrimage in Saudi Arabia, Streptococcus pneumonia, Leptospirosis.
  • Parasites: Angiostrongylus cantonensis, Acanthomoeba, Balamuthia and Naeglerii.

Symptoms occurring more than two weeks, usually 4-6 weeks after travel:

  • Fungi: Histoplasmosis and Coccidioidomycosis can occur in travelers to Mexico, Central America, Midwestern and Southwestern United States respectively.
  • Mycobacteria: Mycobacterium tuberculosis
  • Parasites: African trypanosomiasis caused by T.b. rhodesiense

Returning traveler with fever and no other symptoms

Fever without other associated symptoms was the most common diagnosis in returning travelers seeking medical care, ranging from 25-49% depending on the region of travel.

Fevers may be associated with some headaches and muscle pains, but no other symptoms to suggest an organ involvement. The most common causes of this syndrome are Malaria, Dengue, Rickettsial infections, Typhoid/Paratyphoid fever and Mononucleosis (Epstein-Barr Virus/Cytomegalovirus).

The frequency of the above infections vary depending on the area that one has traveled to, for example malaria is the most frequent cause of fever without other symptoms for travelers from sub-Saharan Africa while dengue is the most common cause among travelers from southeast Asia.
Common pathogens responsible for causing fever without other common symptoms are described below:

Fever without symptoms occurring within two weeks of travel:

  • Malaria – Plasmodium falciparum species
  • Dengue
  • Rickettsial Infection
  • Typhoid/Paratyphoid fever
  • Leptospirosis
  • Acute African Trypanosomiasis (T.b. rhodesiense)
  • Acute HIV infection

Fever without symptoms occurring more than two weeks after travel:

  • Malaria – Plasmodium vivax and ovale species
  • Mononucleosis (Epstein-Barr Virus/Cytomegalovirus).
  • Acute Schistosomiasis
  • Tuberculosis
  • Hepatitis A, B & E
  • Amoebic Liver Abscess
  • Brucellosis
  • Filariasis

Returning traveler with fever and respiratory symptoms

Nearly 10-15% of returning travelers presenting with fever have associated respiratory symptoms. Respiratory symptoms include cough, shortness of breath, productive phlegm, chest congestion and chest pain.
Common pathogens responsible for fever and respiratory infections are described below. 

Symptoms occurring within two weeks of travel:

  • Viruses: Influenza virus, Adenovirus, RSV virus, Rhinovirus. International air travelers also need to keep in mind possibilities like SARS and Swine Influenza H1/N1. Hanta virus can be the culprit in travelers to the Southwestern United States.
  • Bacteria: Streptococcus pneumonia, Mycoplasma pneumonia, Hemophilus influenza, Chlamydia pneumonia. Q fever is a pneumonia associated with animal exposures and is associated with elevated liver enzymes.
  • Fungi: Histoplasmosis and Coccidioidomycosis can occur in travelers to Mexico, Central America and Midwestern & Southwestern United States respectively.

Symptoms occuring more than two weeks, usually 4-6 weeks after travel:

  • Mycobacteria: Mycobacterium tuberculosis is a possible culprit, especially if one traveled to developing countries and symptoms occur 6 or more weeks after travel.
  • Fungi: Chronic phase of Histoplasmosis and Coccidioidomycosis infections.
  • Parasites: Migration of the larvae of Hookworms, Ascaris, Strongyloides etc through the lung can cause respiratory symptoms and high blood eosinophil counts.

Returning traveler with fever and sexual exposures

When it comes to inquiring about travel experiences, sexual exposure history falls into the ‘don’t ask & don’t tell’ category. However, studies have shown that nearly 15-19% of overseas travelers engage in sexual relations with a new partner and 6% of them contract a sexually transmitted disease.

Those who contract sexually transmitted disease don’t always manifest genital lesions and many lesions and discharges resolve spontaneously and individuals are reluctant to disclose this fact.

Fever can be a manifestation of disseminated sexually transmitted disease and needs to be inquired about if there are no obvious explanations for fever, as part of the evaluation.

Common pathogens responsible for fever in the setting of sexual exposures are described below:

Symptoms occur within two to four weeks after travel:

  • Acute HIV infection
  • Syphilis
  • Disseminated Gonorrhea
  • Hepatitis A, B and rarely C
  • Cytomegalovirus
  • Epstein-Barr Virus

Returning traveler with skin rash

Skin disorders are the third most common type of illness in travelers returning from overseas trips ranking behind fever and diarrhea. Skin disorders include allergic reactions to medications taken for the trip, sun burn, insect bites, infections caused by direct entry of pathogen through skin and secondary manifestations of a generalized infection.

Rashes are commonly seen in association with infection including Rickettsia, Lyme, Leptospirosis, Coccidiodes, Histoplasmosis, Dengue, Hemorrhagic viral diseases etc and are described in those sections separately.

The frequency of primary skin disorders vary depending on the region of travel; to help travelers have a better understanding of the type of skin disorder that is seen in association with travel to an area, we have listed them in descending order of frequency.

Caribbean

  • Cutaneous larvae migrans
  • Insect bite
  • Allergic rash
  • Fungal infection
  • Skin abscess
  • Animal bite
  • Swimmer’s itch
  • Impetigo/erysipelas
  • Scabies 

Central America

  • Insect bite
  • Cutaneous larvae migrans
  • Allergic rash
  • Myiasis
  • Leishmaniasis
  • Skin abscess
  • Scabies
  • Impetigo/erysipelas
  • Fungal infection

South America

  • Insect bite
  • Leishmaniasis
  • Cutaneous larvae migrans
  • Myiasis
  • Allergic rash
  • Skin abscess
  • Scabies
  • Fungal infection
  • Animal bite

Sub-Saharan Africa

  • Insect bite
  • Skin abscess
  • Allergic rash
  • Cutaneous larvae migrans
  • Fungal infection
  • Myiasis
  • Impetigo/erysipelas
  • Leishmaniasis
  • Scabies

South Central Asia

  • Insect bite
  • Skin abscess
  • Allergic rash
  • Fungal infection
  • Cutaneous larva migrans
  • Impetigo/erysipelas
  • Scabies
  • Leishmaniasis

South East Asia

  • Insect bite
  • Cutaneous larva migrans
  • Animal bite
  • Skin abscess
  • Allergic rash
  • Impetigo
  • Scabies

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