Careful assessment of travelers with fever must involve a detailed history, a thorough examination, and targeted laboratory investigations. The following are essential in the clinical management of fever in the returning traveler:

The most common tropical fevers in travelers are malaria, enteric fever, hepatitis, amebic liver abscess, and rickettsial and arboviral infections.

Malaria

Malaria is the most important potentially fatal cause of fever in travelers returning from the tropics. Thus, all febrile travelers returning from malaria endemic areas must be evaluated for malaria, even those who have taken appropriate malaria chemoprophylaxis. Antimalarial prophylaxis regimens cannot be considered fully protective.

Nearly all malaria due to Plasmodium falciparum present with fever within 4 weeks of returning but could present several months after leaving a malarious area. Plasmodium vivax and Plasmodium ovale malaria may occur up to 3 years after exposure due to persistence of hypnozoites (latent parasites) in the liver. Plasmodium malariae, which does not have a latent liver phase, is the least common species causing fever in travelers, but may present up to a year or longer (up to 20 years) after first infection. Typical symptoms are high fever, shaking, chills, sweats, headache, and myalgias. Symptoms may be modified or masked according to the immune status, as in an immune native of an endemic area, or by the use of prophylactic antimalarial drugs. Severe Plasmodium falciparum infections can rapidly lead to such lethal complications as cerebral malaria, renal failure, severe hemolysis, and adult respiratory distress syndrome.

Diagnosis is by appropriately prepared and carefully examined Giemsa-stained thin and thick malaria smears. A single negative set of smears cannot rule out malaria; smears should be repeated at 6-hour intervals for at least 24 hours. Rapid malaria antigen detection tests are now available. Specific prophylaxis and therapy for malaria is discussed in Chapter 200, Malaria.

Enteric fever (typhoid and paratyphoid)

Typhoid and paratyphoid fevers can be contracted from contaminated food or water where the prevalence of these bacteria is high. Typhoid vaccines offer protection to no more than 70% of recipients. Enteric fever should be suspected in travelers returning from an endemic area with fever, headaches, abdominal pain, diarrhea, or cough. Symptoms may not develop until several weeks after return. Diagnosis is confirmed by positive blood, stool, or urine culture. The agglutinin test (Widal) lacks sensitivity and specificity and is not recommended. Newer rapid serologic tests that detect IgM antibodies to Salmonella typhi antigens are available. Blood and bone marrow cultures have the highest yield within 1 week of symptoms and urine and stool cultures become positive after the first week.

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