Episode 77 Fever in the Returning Traveler

In this EM Cases episode with Dr. Nazanin Meshkat, multinational ED doc and Dr. Matthew Muller, infectious disease specialist, we discuss the most common tropical disease killers that we see in patients who present with Fever in the Returning Traveler. Every year an increasing number of people travel abroad, and travelers to tropical destinations are often immunologically naïve to the regions they’re going to. It’s very common for travelers to get sick. In fact, about 2/3 of travelers get sick while they’re traveling or soon after their return, and somewhere between 3 and 19% of travelers to developing countries will develop a fever.

Imported diseases, like Malaria, Dengue, Ebola, and Zyka can be acquired abroad and brought back to your ED in unsuspecting individuals. This is serious stuff - you might be surprised to learn that Malaria is responsible for more morbidity and mortality worldwide than any other illness.

According to a study in CJEM most emergency physicians have minimal or no specific training in tropical diseases and emergency physicians indicated an unacceptably low level of comfort when faced with patients with tropical disease symptoms. In fact, 40% of the cases were incorrectly diagnosed or managed. And Canadian ED docs aren’t the only ones who’s skill isn’t stellar in this department - a similar 2006 study of UK physicians showed a 78% misdiagnosis rate. This misdiagnosis rate isn’t wholly because of lack of knowledge – it almost certainly also has to do with the vague presentations and huge amount of overlap between so many tropical disease.

You might be thinking that it’s impossible to learn all the thousands of details of the dozens of different tropical diseases - true. However, in the ED, while we don’t need to know every detail of every tropical disease, and don’t necessarily need to make the exact diagnosis right away, we do need to have a rational, organized approach to diagnosing and managing fever in the returning traveler, so that we can identify some of the more common serious illnesses like Malaria, Dengue and Typhoid fever, and start timely treatment in the ED.



The topic for this podcast was chosen based on a needs assessment conducted by Dr. Meshkat and published in CJEM in 2014.

Podcast recording April 2015; written summary and blog post by Keerat Grewal and Anton Helman, March 2016.

Cite this podcast as: Helman, A, Meshkat, N, Muller, M. Fever in the Returning Traveler. Emergency Medicine Cases. March, 2016. https://emergencymedicinecases.com/fever-returning-traveler/. Accessed [date].

Fever in the returning traveler is usually not caused by a dangerous tropical disease. These patients are much more likely to have typical viral illnesses as a cause for their fever. Nonetheless, all patients who return from traveling to a tropical destination with a fever require consideration of the common deadly tropical diseases: Malaria, Dengue and Typhoid fever.

  For A Rational Approach to Emergency Preparedness in the returning traveler suspected of high risk contagious disease go to this special EM Cases episode with Howard Ovens

Case 1 General approach to fever in the returning traveler

A 60 year-old male, presents with a fever to your ED. He recently returned from India, where he spent 3 weeks visiting relatives. He has no significant past medical history. Immunizations are up to date. He did id not receive any travel immunizations or malaria prophylaxis. The fever started 2 days ago, and is associated with cough and chills. In the ED his vital signs are: Temp 38.4°C, BP 135/85,