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A 35-year-old graduate student at the local university returned from visiting his family in Liberia over the summer. He has been back in the United States for a week, and three days ago he began having fevers up to 40°C (104°F). He has had shaking chills, significant body aches, and a faint papular rash noted on his torso. Initial laboratory studies include a single negative malaria smear and a negative malaria rapid diagnostic test. A CBC reveals WBC count of 5000 with a left shift noted, and his platelet count is low at 120,000. Upon further history, the student reported a tick bite while visiting his family in the rural parts of the country. He reports no known contact with ill people or participation in any funerals or burial rituals in the country. He is admitted to the hospital for supportive management. Because of his history of recent travel to western Africa, the Centers for Disease Control and Prevention (CDC) is notified, and serologies for Ebola, dengue, chikungunya, and African tick-bite fever are sent. In addition to careful fluid and electrolyte management, he is empirically started on doxycycline for the possibility of rickettsial diseases while awaiting the results of the serologic tests. After 24 hours, his fever improves, and he is monitored for vascular leakage and hypotension, but recovers well. IgM for dengue ultimately returns positive.
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Travel has dramatically increased over the past 50 years, both in number of travelers and in distances traveled. Diseases once isolated to restricted geographic areas now must often be included in the differential diagnosis and management of people throughout the world. Failure to diagnose certain critical illnesses not only can lead to worsened clinical outcomes, but also may pose a significant public health threat. Diagnosing emerging infections can be difficult because many of them have nonspecific findings in early stages, and definitive testing often requires reference laboratory testing that may take days to weeks for results. Clinicians need to be aware of current disease outbreaks in their areas, and they need to obtain relevant travel history, including the patient's travel destinations, activities while traveling, insect bites, water exposure, prophylaxis used, and the timing of symptoms relevant to travel.
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Zika virus was originally described in monkeys in the Zika Forest of Uganda in 1947, with the first human case described in 1952.1 The first Zika outbreak outside of Africa and Asia was described in Yap Island in Micronesia in 2007.2 Subsequently, the largest known outbreak of Zika virus was identified in Brazil in 2015, and the causal link between Zika infection in pregnancy and serious fetal anomalies such as microcephaly was identified.3 The first locally acquired case of Zika in the United States was diagnosed on July 7, ...