Travel-Related Infections

Fever and Rash

Infectious causes of fever and rash pose a diagnostic challenge for the emergency provider. It is often difficult to discern rashes associated with rapidly progressive and life-threatening infections from benign exanthems, which comprise the majority of rashes seen in the emergency department. Physicians must also consider serious noninfectious causes of fever and rash. A correct diagnosis depends on an exhaustive history and head-to-toe skin examination as most emergent causes of fever and rash remain clinical diagnoses. A provisional diagnosis and immediate treatment with antimicrobials and supportive care are usually required prior to the return of confirmatory laboratory testing.

[Diagnostic protocol for imported febrile syndrome]

In this protocol we shall set out the steps to follow in the clinical assessment of the patient with fever and where there is an epidemiological history of travel to tropical or subtropical areas. This is not intended to be exhaustive, but as a guide to doctors in their initial diagnostic approach to the patient who has come from the tropics consulting with a fever in the Emergency Department or the hospital ward. Differential diagnosis should be approached first and foremost on the basis of excluding malaria, but haemorrhagic fevers, rickettsiosis, typhoid fever and many other infections, some that are unique to tropical areas, and others that are cosmopolitan but more prevalent in such areas should also be taken into account.

First report of furuncular myiasis caused by the larva of botfly, Dermatobia hominis, in a Taiwanese traveler

A case of furuncular myiasis was reported for the first time in a 29-year-old young Taiwanese traveler returning from an ecotourism in Peru. Furuncle-like lesions were observed on the top of his head and he complained of crawling sensations within his scalp. The invasive larva of botfly, Dermatobia hominis, was extruded from the furuncular lesion of the patient. Awareness of cutaneous myiasis for clinicians should be considered for a patient who has a furuncular lesion and has recently returned from a botfly-endemic area.

Unusual cause of recurrent fever after travel in South America

Fever in returning travelers is a common problem and usually the diagnosis is made within a few days or the traveler recovers.

We present two travelers who presented with fever two weeks after returning from a six week vacation in South America. Over the following 18 months they presented with short attacks of fever, elevated CRP and leukocytosis and the program for investigation became more and more elaborate. A curious and key feature was, that they were completely synchronous both developing symptoms within an hour and presentation with the same laboratory findings of leukocytosis and elevated CRP. Extensive and repeated tests were performed, at our facility and abroad. After a year it was discovered that the uses of aroma oils were associated with the symptoms. No similar case has been found to be reported previously.

These cases emphasize that natural products are not inherently safe. The investigational program was build up over time as new attacks continued to occur and suggestions from different centers which were consulted were followed up. The number of tests performed at different laboratories took an extensive amount of time. These cases emphasize that a panel of analysis in returning travelers in which no clear diagnosis is found should be developed.

Malaria in pregnancy: update on emergency management

BACKGROUND

Pregnancy complicates the diagnosis, treatment, and clinical course of malaria. This clinical problem may be encountered in emergency department patients due to international travel.

CASE REPORT

A primigravida woman at 20 weeks gestation presented to the Emergency Department with episodic fever, chills, headache, and nausea after travel to India and Asia. She had not taken malaria prophylaxis. After hospitalization, she developed acute respiratory distress syndrome and required intensive care management. Although she ultimately recovered from severe infection with Plasmodium vivax, she was not able to sustain her pregnancy and suffered a miscarriage.

CONCLUSION

This case illustrates the serious nature of malaria in the pregnant patient. For this high-risk group, there is an increased incidence of severe anemia, as well as acute respiratory distress syndrome and pulmonary edema. A guideline is presented for the initial choice of anti-malarial drug treatment for the pregnant patient.

Modeling the risk of malaria for travelers to areas with stable malaria transmission

Background

Malaria is an important threat to travelers visiting endemic regions. The risk of acquiring malaria is complex and a number of factors including transmission intensity, duration of exposure, season of the year and use of chemoprophylaxis have to be taken into account estimating risk.

Materials and methods

A mathematical model was developed to estimate the risk of non-immune individual acquiring falciparum malaria when traveling to the Amazon region of Brazil. The risk of malaria infection to travelers was calculated as a function of duration of exposure and season of arrival.

Results

The results suggest significant variation of risk for non-immune travelers depending on arrival season, duration of the visit and transmission intensity. The calculated risk for visitors staying longer than 4 months during peak transmission was 0.5% per visit.

Conclusions

Risk estimates based on mathematical modeling based on accurate data can be a valuable tool in assessing risk/benefits and cost/benefits when deciding on the value of interventions for travelers to malaria endemic regions.