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Chapter 5Post-Travel Evaluation

General Approach to the Returned Traveler

Jessica K. Fairley

THE POST-TRAVEL EVALUATION

Travel-related health problems have been reported in as many as 22%–64% of travelers to developing countries. Although most of these illnesses are mild, up to 8% of travelers are ill enough to seek care from a medical provider. Most post-travel infections become apparent soon after travel, but incubation periods vary, and some syndromes can present months to years after initial infection. When evaluating a patient with a probable travel-related illness, the clinician should consider the items summarized in Box 5-01.

The Severity of Illness

The first item to assess in ill returned travelers is the severity of illness. Is this a potentially life-threatening infection, such as malaria? A severe respiratory syndrome or signs of hemorrhagic fever are examples of cases that may also necessitate prompt involvement of public health authorities. See “Management” below for more details.

Travel Itinerary

The itinerary is crucial to formulating a differential diagnosis, because potential exposures differ depending on the region of travel. A febrile illness with nonspecific symptoms could be malaria, dengue, typhoid fever, or rickettsial disease, among others. Being able to exclude certain infections will avoid unnecessary testing. A study from the GeoSentinel Surveillance Network found that systemic febrile illness was more often associated with travel to sub-Saharan Africa or Southeast Asia, while acute diarrhea was more common from south-central Asia. The duration of travel is also important, since the risk of a travel-related illness increases with the length of the trip. A tropical medicine specialist can assist with the differential diagnosis and may be aware of outbreaks or the current prevalence of an infectious disease in an area.

Timing of Illness in Relation to Travel

Most ill travelers will seek medical attention within 1 month of return from their destination, because most common travel-related infections have short incubation periods. Occasionally, however, infections such as schistosomiasis, leishmaniasis, or Chagas disease can manifest months or even years later. Therefore, in unusual cases, a detailed history that extends beyond a few months before presentation can be helpful. The most common travel-related infections with short incubation periods are listed in Table 5-01.

Underlying Medical Illness

Comorbidities can affect the susceptibility to infection, as well as the clinical manifestations and severity of illness. An increasing number of immunosuppressed people (due to organ transplants, immune-modulating medications, HIV infection, or other primary or acquired immunodeficiencies) are international travelers (see Chapter 8, Immunocompromised Travelers).

Vaccines Received and Prophylaxis Used

The history of vaccinations and malaria chemoprophylaxis should be reviewed when evaluating an ill returned traveler. Less than half of US travelers to developing countries seek pre-travel medical advice and may not have received vaccines or taken antimalarial drugs. Although adherence to malaria chemoprophylaxis does not rule out the possibility of malaria, it reduces the risk and increases the chance of an alternative diagnosis. Fever and a rash in a traveler without an up-to-date measles vaccination would raise concern about measles. The most common vaccine-preventable diseases found in a large 2010 GeoSentinel study of returned travelers included enteric fever (typhoid and paratyphoid), viral hepatitis, and influenza. More than half of these patients with vaccine-preventable diseases were hospitalized.

Individual Exposure History

Knowledge of the patient’s exposures during travel, including insect bites, contaminated food or water, or freshwater swimming, can also assist with the differential diagnosis. In addition to malarial parasites, mosquitoes can transmit viruses (such as dengue virus, yellow fever virus, and chikungunya virus) and filarial parasites (such as Wuchereria bancrofti). Depending on the clinical syndrome, a history of a tick bite could suggest a diagnosis of tickborne encephalitis, African tick-bite fever, or other rickettsial infections. Tsetse flies are large, and their bites are painful and often recalled by the patient. They can carry Trypanosoma brucei, the protozoan that causes African sleeping sickness. Freshwater swimming or other water contact can put the patient at risk for schistosomiasis, leptospirosis, and other diseases.

The purpose of the patient’s trip and the type of accommodations can also influence the risk for acquiring certain diseases. Travelers who visit friends and relatives are at higher risk of malaria, typhoid fever, and certain other diseases, probably because, compared with tourists, they stay longer, travel to more remote destinations, have more contact with local water sources, and do not seek pre-travel advice (see Chapter 8, Immigrants Returning Home to Visit Friends & Relatives [VFRs]). Someone backpacking and camping in rural areas will also have a higher risk of certain diseases than those staying in luxury, air-conditioned hotels.

Box 5-01. Important elements of a medical history in an ill returned traveler

  • Severity of illness
  • Travel itinerary and duration of travel
  • Timing of onset of illness in relation to international travel
  • Past medical history and medications
  • History of a pre-travel consultation
    • Travel immunizations
    • Adherence to malaria chemoprophylaxis
  • Individual exposures
    • Type of accommodations
    • 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
    • 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)

Table 5-01. Illnesses associated with fever presenting in the first 2 weeks after travel

SYNDROME POSSIBLE CAUSE
Systemic febrile illness with initial nonspecific symptoms Malaria
Dengue
Typhoid fever
Rickettsial diseases (such as scrub typhus, relapsing fever)
East African trypanosomiasis
Acute HIV infection
Leptospirosis
Fever and central nervous system involvement Meningococcal meningitis
Malaria
Arboviral encephalitis (such as Japanese encephalitis virus, West Nile virus)
East African trypanosomiasis
Angiostrongyliasis
Rabies
Fever with respiratory complaints Influenza
Bacterial pneumonia
Acute histoplasmosis or coccidioidomycosis,
Legionella pneumonia
Q fever
Malaria
Tularemia
Pneumonic plague
Fever and skin rash Dengue
Measles
Varicella
Spotted-fever or typhus group rickettsiosis
Typhoid fever
Parvovirus B19
Mononucleosis
Acute HIV infection

COMMON SYNDROMES

The most common clinical presentations after travel to developing countries include systemic febrile illness, acute diarrhea, and dermatologic conditions. These are described in more detail in the following sections of this chapter (Fever in Returned Travelers, Persistent Travelers’ Diarrhea, and Skin & Soft Tissue Infections in Returned Travelers). Fever in a traveler returning from a malaria-endemic country needs to be evaluated immediately.

Respiratory Complaints

Respiratory complaints are frequent among returned travelers and are typically associated with common respiratory viruses (see Chapter 2, Respiratory Infections). Influenza is one of the most common vaccine-preventable diseases associated with international travel. Severe respiratory symptoms—especially associated with fever—in a returned traveler should alert the physician to common infectious diseases such as seasonal influenza, bacterial pneumonia, and malaria but could also suggest more unusual entities, such as Legionnaires’ disease. In these suspected cases, local public health authorities and CDC should be alerted immediately.

Delayed onset and chronic cough after travel could be tuberculosis, especially in a long-term traveler or health care worker. Other uncommon infections causing respiratory illness after travel to specific regions are histoplasmosis, coccidioidomycosis, Q fever, plague, tularemia, and melioidosis. Helminth infections that produce pulmonary disease include strongyloidiasis, paragonimiasis, and schistosomiasis.

Eosinophilia

Eosinophilia in a returning traveler suggests a possible helminth infection. Allergic diseases, hematologic disorders, and a few other viral, fungal, and protozoan infections can also cause eosinophilia. Fever and eosinophilia can be present during pulmonary migration of parasites, such as hookworm, Ascaris, and Strongyloides. Acute schistosomiasis, or Katayama syndrome, is also a cause of fever and eosinophilia and can be associated with pulmonary infiltrates. Other parasitic infections associated with eosinophilia include chronic strongyloidiasis, visceral larval migrans, lymphatic filariasis, and acute trichinellosis. Findings in a recent outbreak of sarcocystosis in travelers returning from Tioman Island, Malaysia, included myalgia and eosinophilia. The affected travelers had eosinophilic myositis on muscle biopsy.

MANAGEMENT

Most post-travel illnesses can be managed on an outpatient basis, but some patients, especially those with systemic febrile illnesses, may need to be hospitalized. In a 2007 analysis of GeoSentinel data, 46% of returned travelers with systemic febrile illness were hospitalized. Severe presentations, such as acute respiratory distress, mental status change, and hemodynamic instability, require inpatient care. Clinicians should have a low threshold for admitting febrile patients if malaria is suspected. Confirmation of diagnosis can be delayed, and complications can occur rapidly. Management in an inpatient setting is especially important if the patient may not reliably follow up or when no one is at home to assist if symptoms worsen quickly. Consultation with an infectious diseases physician is recommended in severe travel-related infections, when management is complicated, or when the diagnosis remains unclear. A tropical medicine or infectious disease specialist should be involved in cases that require specialized treatment, such as neurocysticercosis, severe malaria, and leishmaniasis, among others. CDC provides on-call assistance with the diagnosis and management of parasitic infections at 404-718-4745 for parasitic infections other than malaria or 770-488-7788 (toll-free at 855-856-4713) for malaria, during business hours. After business hours, call the CDC Emergency Operations Center at 770-488-7100.

BIBLIOGRAPHY

  1. Boggild AK, Castelli F, Gautret P, Torresi J, von Sonnenburg F, Barnett ED, et al. Vaccine preventable diseases in returned international travelers: results from the GeoSentinel Surveillance Network. Vaccine. 2010 Oct 28;28(46):7389–95.
  2. CDC. Notes from the field: acute muscular sarcocystosis among returning travelers—Tioman Island, Malaysia, 2011. MMWR Morb Mortal Wkly Rep. 2012 Jan 20;61(2):37–8.
  3. Chen LH, Wilson ME, Davis X, Loutan L, Schwartz E, Keystone J, et al. Illness in long-term travelers visiting GeoSentinel clinics. Emerg Infect Dis. 2009 Nov;15(11):1773–82.
  4. Franco-Paredes C, Jacob JT, Hidron A, Rodriguez-Morales AJ, Kuhar D, Caliendo AM. Transplantation and tropical infectious diseases. Int J Infect Dis. 2010 Mar;14(3):e189–96.
  5. Freedman DO, Weld LH, Kozarsky PE, Fisk T, Robins R, von Sonnenburg F, et al. Spectrum of disease and relation to place of exposure among ill returned travelers. N Engl J Med. 2006 Jan 12;354(2):119–30.
  6. Hamer DH, Connor BA. Travel health knowledge, attitudes and practices among United States travelers. J Travel Med. 2004 Jan–Feb;11(1):23–6.
  7. Hendel-Paterson B, Swanson SJ. Pediatric travelers visiting friends and relatives (VFR) abroad: illnesses, barriers and pre-travel recommendations. Travel Med Infect Dis. 2011 Jul;9(4):192–203.
  8. Hill DR. Health problems in a large cohort of Americans traveling to developing countries. J Travel Med. 2000 Sep–Oct;7(5):259–66.
  9. Ryan ET, Wilson ME, Kain KC. Illness after international travel. N Engl J Med. 2002 Aug 15;347(7):505–16.
  10. Schulte C, Krebs B, Jelinek T, Nothdurft HD, von Sonnenburg F, Loscher T. Diagnostic significance of blood eosinophilia in returning travelers. Clin Infect Dis. 2002 Feb 1;34(3):407–11.
  11. Wilson ME, Weld LH, Boggild A, Keystone JS, Kain KC, von Sonnenburg F, et al. Fever in returned travelers: results from the GeoSentinel Surveillance Network. Clin Infect Dis. 2007 Jun 15;44(12):1560–8.
 
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