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Returned Traveller

Travellers visiting tropical and developing countries can present to Emergency Departments (EDs) with health problems upon their return. Illness in the returned traveller may be due to rare or tropical infections not commonly seen in Australia, but may also be unrelated to travel and as a result of a common local pathogen.

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History

  • Complete travel history

    • Pre-travel health planning: immunisations, adherence to malaria chemoprophylaxis

    • Dates and places visited, including travel to rural areas.

What infections are possible given the destination(s)? Visit the Center for Disease Control and Prevention for a comprehensive list.

  • Individual exposures

    • Types of accommodation: hotel, budget

    • Insect precautions taken (such as repellent, bed nets)

    • Source of drinking water

    • Ingestion of raw meat or seafood or unpasteurized dairy products

    • Insect or arthropod bites (such as spiders, lice, centipedes, flies)

    • Freshwater exposure (such as swimming, rafting)

    • Animal bites and scratches

    • Body fluid exposure (such as tattoos, sexual activity)

    • Medical care while overseas (such as injections, transfusions).

  • History of presenting symptoms

    • Timing of onset of symptoms in relation to travel.

What is the incubation period of possible infections? Click here for a table of common infections.

  • Past medical history and medications.


Examination

Key examination findings which may indicate specific causes include:

  • Jaundice

  • Hepatosplenomegaly

  • Rashes, eg. Rose spots (typhoid), macular-maculopapular (dengue)

  • Purpura / petechiae (meningococcal)

  • Regional lymphadenopathy

  • Insect bites

Findings that should prompt urgent attention include haemorrhage, purpuric rash, neurologic impairment and acute respiratory distress.


Investigations

Choice of investigations is dependent upon region of travel and a patient’s symptoms/signs and individual risk factors. The following are a reasonable starting point for most returned travellers seen in EDs:

  • FBC, LFT

  • Thick and thin films, taken on two separate occasions

  • Blood cultures

  • Serology for malaria, dengue fever, chikungunya, rickettsia, strongyloides, HIV, Hepatitis A/B/C/E

  • CXR

  • Urine M/C/S (if suspect UTI)

  • Stool cultures +/- OCP.


Returned Traveller with Fever

The initial focus in evaluating a febrile returned traveller should be on identifying infections that are rapidly progressive, treatable, or transmissible.

Presence of associated signs, symptoms, or laboratory findings can focus attention on specific infections.

Common Clinical Findings

Infections to Consider after Tropical Travel

Fever and rash

Dengue

Chikungunya

Rickettsial infections

Enteric fever (skin lesions may be sparse or absent) Acute HIV infection

Measles

Fever and abdominal pain

Enteric fever

Amebic abscess

Undifferentiated fever and normal/low WCC

Dengue

Malaria

Rickettsial infection

Enteric fever

Chikungunya

Fever and haemorrhage

Viral haemorrhagic fevers (dengue and others) Meningococcaemia

Leptospirosis

Rickettsial infections

Fever and eosinophilia

Acute schistosomiasis

Drug hypersensitivity reaction

Fascioliasis and other parasitic infections (rare)

Fever and pulmonary infiltrates

Common bacterial and viral pathogens

Legionellosis

Schistosomiasis

Q fever

Leptospirosis

Fever and altered mental status

Cerebral malaria

Viral or bacterial meningoencephalitis

African trypanosomiasis

Scrub typhus

Mononucleosis syndrome

Epstein-Barr virus infection

Cytomegalocirus infection

Toxoplasmosis

Acute HIV

Fever persisting > 2 weeks

Malaria

Enteric fever

Epstein-Barr virus infection

Cytomegalovirus infection

Toxoplasmosis
Acute HIV

Acute schistosomiasis,
Brucellosis

Tuberculosis

Q fever

Visceral leishmaniasis (rare)

Fever with onset >6 weeks after travel

Plasmodium vivax or ovale malaria

Acute hepatitis (B,C or E)

Tuberculosis,

Amebic liver abscess

Source: Centers for Disease Control and Prevention Yellow Book 2013

Evaluation and initial management of fever is a returned traveller is outlined here (Medical Journal of Australia, 2002. 177 (4): pp. 212-219).

Malaria

  • Malaria is the most common diagnosis amongst Australian travellers suffering from a febrile illness
  • A history of taking anti-malarial prophylaxis does not exclude the possibility of malaria
  • Patients with falciparum malaria require hospital admission as the disease can progress rapidly
  • Urgent treatment is essential if the patient has any of the following feature suggesting severe disease:
    • altered consciousness +/- seizures
    • metabolic acidosis
    • severe anaemia
    • circulatory collapse
    • respiratory distress (ARDS)
    • renal or hepatic failure
Treatment

IV artesunate:

  • 2.4mg/kg IV (adult and child) on admission
  • repeat at 12hr and 24hr
  • then daily until oral therapy tolerated

If artesunate not available, for IV quinine*:

  • 20mg/kg IV (adult and child) over 4hrs as a loading dose
  • then 10mg/kg IV over 4hrs (starting 4hrs after loading dose completed
  • then continue same dose 8-hourly until oral therapy tolerated

*Side effects of quinine include:

- prolonged QTc interval (will require cardiac monitoring during loading dose)

- hypoglycaemia.

Dengue

  • Endemic throughout the tropics and subtropics. Dengue is a leading cause of febrile illness among travellers returning from the Pacific, the Caribbean, South America, Pacific Islands and South/Southeast Asia. Spread via the A aegypti mosquito, which – unlike other mosquitoes – bites during the day.
  • Primary or first infection is usually benign (and may go unnoticed), whereas subsequent infections cause an immune response which can result in more severe illness. Severe, albeit rare, manifestations include dengue shock syndrome and haemorrhagic fever.
  • Characterised by short incubation period followed by abrupt onset of:
    • high fever
    • backache, myalgia, arthralgia or bone pain
    • frontal and retro-orbital headache
    • malaise, anorexia, vomiting
  • Examination findings include:
    • Flushed appearance progressing to generalised maculopapular or rubelliform rash
    • Haemorrhagic signs: petechiae, purpura or positive tourniquet test (see WHO resource 2009)
  • Characteristic investigation findings:
    • FBC: thrombocytopenia, leukopenia, elevated haematocrit
    • LFTS: hypoalbuminaemia, elevated ALT:AST ratio
    • Non-structural protein 1, PCR - positive early infection. IgG + IgM are tests of choice after 5 days of illness
  • Treatment is largely supportive with analgesia and fluid and electrolyte replacement. Patients should be encouraged to take fluids orally (approx. 2.5 litres / 24h), with paracetamol as required for pain or fever. Opiates may be required for severe pain. NSAIDs increase bleeding risk and should be avoided.
  • Some patients can progress to a critical phase of infection characterised by plasma leakage, bleeding, shock and organ impairment. This critical phase can be heralded by specific warning signs:
    • Abdominal pain or tenderness
    • Persistent vomiting
    • Accumulation of fluid (e.g. ascites, pleural effusion)
    • Mucosal bleeding
    • Lethargy or restlessness
    • Liver enlargement >2cm
    • Increase in haemotacrit with rapid decrease in platelet count
  • The WHO classifies patients in 3 groups based on disease severity to guide management:
    • Group A: no warning signs, can tolerate adequate oral fluids and pass urine every 6 hours, with near normal blood counts. Can be managed at home.
    • Group B: developing warning signs, risk-factors (diabetes, obesity, pregnancy, renal failure), poor social support, increasing haematocrit or rapidly declining platelets. Should be managed in hospital.
    • Group C: severe plasma leakage with shock +/- fluid accumulation causing respiratory distress; severe bleeding; severe organ impairment. Require emergency treatment with access to ICU and blood products.
Further References and Resources

Enteric fever (typhoid and paratyphoid)

  • Systemic infection with the bacterium Salmonella enterica serotype typhi
  • Ingestion of contaminanted food / water
  • Typhoid vaccine confers about 70% protection, so does not rule out the diagnosis
  • Characterised by fever, malaise, poorly localised abdominal discomfort, myalgia, hepatosplenomegaly, blanching erythematous maculopapular rash
Treatment
  • Azithromycin 1g (child: 20mg/kg up to 1g) PO for 5 days.
  • CSF analysis should be performed in all neonates and children younger than three months to exclude neurological disease. Treatment should be extended to 10 days in this age group, and administered IV throughout. Children three to 12 months should be treated for 7 days, with initial therapy given IV.

Returned Traveller with Respiratory Infection

Respiratory complaints are frequent among returned travellers and are typically associated with common respiratory viruses. Influenza is one of the most common vaccine-preventable diseases associated with international travel. Severe respiratory symptoms associated with fever in a returned traveller are likely to be caused by common infectious diseases such as influenza, bacterial pneumonia, and malaria but could also suggest more unusual entities, such as Legionnaires’ disease. Other non-infectious causes, such as pulmonary emboli, should also be considered. Delayed onset and chronic cough after travel could be tuberculosis.


Returned Traveller with Diarrhoea

Most cases of travellers’ diarrhoea are the result of bacterial infection and are short-lived and self-limited. Mean duration of symptoms is four days. When symptoms persist for 14 days or more, bacterial causes are less likely. Parasites as a group are the pathogens most likely to be isolated from patients with persistent diarrhoea, and their probability relative to bacterial infections increases with increasing duration of symptoms. An approach to the investigation and management returned travellers with persistent diarrhoea is outlined here (Medical Journal of Australia, 2002. 177 (4): pp. 212-219).

In some cases, persistence of gastrointestinal symptoms relates to chronic underlying gastrointestinal disease, such as coeliac disease or inflammatory bowel disease. Therefore a more comprehensive search for underlying causes of chronic diarrhoea could be considered.


Management

Most illnesses in returned travellers can be managed on an outpatient basis, but some patients may need to be hospitalised. Patients with systemic febrile illnesses and other severe presentations, such as those with respiratory distress, mental status change and haemodynamic instability, will require inpatient care. Inpatient management is especially important for those who may not reliably follow up or when there is high likelihood of rapid clinical deterioration.

Consultation with Infectious Diseases Specialist team is recommended for management of patients with severe travel-related infections, where there is diagnostic uncertainty, or when management is complicated.

Infection Control

Clinical suspicion of certain travel-related infections should prompt the initiation of additional infection control precautions. Airborne and droplet precautions may need to be added to standard contact precautions. NSW Health have produced this table outlining those infectious diseases requiring additional precautions.

Notification

Many illnesses in returned travellers are notifiable diseases. See NSW Health's Infectious Diseases page for more information.


Further References and Resources

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