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Key Clinical Questions

  • image What infections should be considered?

  • image What questions should be asked in the travel history?

  • image What diagnostic tests should be conducted?

  • image Which patients should be hospitalized?

  • image What clinical factors put patients at risk for serious complications?

  • image When should an infectious disease physician be consulted?

International travelers are commonly plagued by medical problems, particularly after travel to a resource-poor setting. About 8% of travelers to developing countries seek medical care while they are away or after they return. Although fever in the traveler may be caused by mild illnesses, it may also be a harbinger of potentially lethal infection. The evaluation of the febrile traveler is complicated by the wide array of possible etiologies. It is critical to consider the infections are endemic to the area visited, potential exposures, time between exposure and the onset of symptoms, and associated clinical findings. This chapter reviews the common causes of fever in returning travelers and the appropriate initial evaluation.


GeoSentinel, a worldwide network of travel and tropical medicine clinics, provides the largest database for travel-related infections. From 1996 to 2004, the five most common diagnoses for patients with systemic febrile illnesses presenting to GeoSentinel clinics from the developing world were malaria, dengue, mononucleosis due to Epstein-Barr virus or cytomegalovirus, rickettsial infection, and typhoid fever. GeoSentinel clinic data from 2007 to 2011 were similar. Malaria was the top overall diagnosis, followed by dengue, typhoid and paratyphoid fevers, and rickettsial disease. The emerging infection chikungunya virus rounded out the top five.

Malaria remains the leading cause of systemic febrile illness in travelers returning from Sub-Saharan Africa, and it was one of the three top causes from all regions of the developing world. In the United States, more than 50% of cases of imported malaria occurred among immigrant families who had made recent visits to their country of origin. Dengue was the leading cause for fever in travelers to Southeast Asia, Latin America, and the Caribbean. Rickettsial infections were an important cause of fever in travelers to Sub-Saharan Africa, who often had Rickettsia africae (African tick-bite fever). Typhoid fever was most common in travelers to South Central Asia, especially in travelers to India, Pakistan, Bangladesh, and Nepal, but cases also occurred in travelers to other regions. Other notable diagnoses among febrile travelers with systemic illness included viral hepatitis, leptospirosis, tuberculosis, brucellosis, measles, and acute HIV.

Among patients with fever and diarrhea, the most common diagnoses were traveler’s diarrhea, Campylobacter, nontyphoidal Salmonella species, and shigellosis. In those with fever and respiratory symptoms, nearly half were diagnosed with bronchitis or an acute unspecified respiratory infection. Other common diagnoses were bacterial pneumonia, tonsillitis, influenza or an influenza-like illness, and sinusitis.


It is critical to identify all regions that the traveler has visited ...

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