Diagnosis of Fever in the Returning Child Traveller
The seriously ill child is managed immediately according to advanced paediatric life support (APLS) principles in consultation with an infectious disease specialist.
A comprehensive medical and travel history together with clinical examination are essential and should be undertaken as described below.
A detailed history of all travel destinations including transit points within the previous 12 months (not just the most recent trip) enables consideration of infections more prevalent in or limited to certain geographic regions. The risk of exposure may vary from high to non-existent within the same country, from rural to urban areas and from lower to higher altitudes. Several resources are available that can provide guidance on the risk from infections in different regions of the world.
Precise travel dates enable the exclusion of certain infections by virtue of their incubation periods. For instance, malaria may be excluded if symptoms occur <7 days after the first possible exposure. Similarly dengue can be excluded if the onset of symptoms occur >14 days after the last possible exposure.
The season of travel may be important. For example, the risk from malaria is usually highest during the rainy season and from meningococcal disease in the meningitis belt of sub-Saharan Africa during the dry season. Prolonged travel is associated with an increased risk of exposure to infections.
The proportion of children visiting friends and relatives (VFR) abroad has increased more than any other reason for travelling. They tend to be at increased risk from infections by virtue of living in closer proximity to the local population; consuming locally prepared foods and drinks; travelling for longer periods; and being less likely to take prophylactic precautions and seek pretravel and post-travel health advice.
Certain activities undertaken while abroad are associated with specific infections. Freshwater recreational activities are associated with leptosporosis and schistosomiasis in certain regions. Children have an increased tendency to play with animals including dogs and monkeys predisposing them to zoonotic infections such as rabies.
Camping, budget accommodation and living in close proximity to the local population are associated with an increased risk of malaria, typhus and meningococcal disease.
The risk of food and waterborne infections depends upon how hygienically food is prepared and consumed. Raw, undercooked and reheated food, as well as non-sterilised water, are associated with typhoid fever, travellers' diarrhoea, viral hepatitis A and E and fascioliasis. Unpasteurised dairy products are associated with brucellosis, salmonellosis and listeriosis.
Dates of routine and travel-specific vaccination schedules, including boosters, are important to ascertain whether sufficient protection was provided prior to departure. While certain vaccines, such as hepatitis A and yellow fever provide almost complete protection, others such as typhoid fever are less effective (<70%).
For travel to malaria endemic areas, details on whether malaria chemoprophylaxis was taken including supervision/compliance is important. While Atovaquone/proguanil should be taken daily until 7 days after the last potential exposure, mefloquine should be taken weekly until 4 weeks after the last potential exposure. The use of mosquito nets, long sleeved clothing and N,N-Diethyl-meta-toluamide, and whether the child sustained insect bites, are important when considering arthropod-borne infections.
Current comorbidities and medications, especially those that are immunosuppressive, may predispose the child to infections. A child with splenic dysfunction, for example, sickle cell disease, is at increased risk of malaria and encapsulated organisms such as pneumococcus. Medical care received abroad may be inadequate. Incomplete courses of substandard antimalarials and antibiotics may lead to partially treated infections. Details of unwell travel contacts or companions may have diagnostic and public health implications.
A complete systems review, including the date of onset and sequence that symptoms present, is important. Associated symptoms, such as a cough or abdominal pain, may help to localise the infection although symptoms may yet manifest in the acute presentation. The pattern and duration of fever may be important, however, the traditional tertian pattern in Plasmodium falciparum malaria is rarely seen in children. Many infections present with a non-specific fever and a variety of associated symptoms. Care must be taken particularly in the acute phase that associated symptoms do not lead to misdiagnosis through inappropriate localisation of the infection.
A complete physical examination is important to elicit signs associated with certain infections. This should include an assessment of the child's weight and nutritional status. However, the absence of associated signs and symptoms does not necessarily exclude diagnoses. Skin rashes are often non-specific, but may be characteristic of specific infections or indicate potentially serious infection, such as the petechiae/purpura of meningoccocal disease and viral haemorrhagic fevers (VHF). Lymphadenopathy, hepatomegaly, splenomegaly and jaundice are each associated with a variety of infectious and non-infectious causes (Table 1).
Initial Assessment
The seriously ill child is managed immediately according to advanced paediatric life support (APLS) principles in consultation with an infectious disease specialist.
A comprehensive medical and travel history together with clinical examination are essential and should be undertaken as described below.
Destinations and Dates of Travel
A detailed history of all travel destinations including transit points within the previous 12 months (not just the most recent trip) enables consideration of infections more prevalent in or limited to certain geographic regions. The risk of exposure may vary from high to non-existent within the same country, from rural to urban areas and from lower to higher altitudes. Several resources are available that can provide guidance on the risk from infections in different regions of the world.
Precise travel dates enable the exclusion of certain infections by virtue of their incubation periods. For instance, malaria may be excluded if symptoms occur <7 days after the first possible exposure. Similarly dengue can be excluded if the onset of symptoms occur >14 days after the last possible exposure.
The season of travel may be important. For example, the risk from malaria is usually highest during the rainy season and from meningococcal disease in the meningitis belt of sub-Saharan Africa during the dry season. Prolonged travel is associated with an increased risk of exposure to infections.
Purpose of Travel and Activities
The proportion of children visiting friends and relatives (VFR) abroad has increased more than any other reason for travelling. They tend to be at increased risk from infections by virtue of living in closer proximity to the local population; consuming locally prepared foods and drinks; travelling for longer periods; and being less likely to take prophylactic precautions and seek pretravel and post-travel health advice.
Certain activities undertaken while abroad are associated with specific infections. Freshwater recreational activities are associated with leptosporosis and schistosomiasis in certain regions. Children have an increased tendency to play with animals including dogs and monkeys predisposing them to zoonotic infections such as rabies.
Living Conditions
Camping, budget accommodation and living in close proximity to the local population are associated with an increased risk of malaria, typhus and meningococcal disease.
The risk of food and waterborne infections depends upon how hygienically food is prepared and consumed. Raw, undercooked and reheated food, as well as non-sterilised water, are associated with typhoid fever, travellers' diarrhoea, viral hepatitis A and E and fascioliasis. Unpasteurised dairy products are associated with brucellosis, salmonellosis and listeriosis.
Prophylaxis
Dates of routine and travel-specific vaccination schedules, including boosters, are important to ascertain whether sufficient protection was provided prior to departure. While certain vaccines, such as hepatitis A and yellow fever provide almost complete protection, others such as typhoid fever are less effective (<70%).
For travel to malaria endemic areas, details on whether malaria chemoprophylaxis was taken including supervision/compliance is important. While Atovaquone/proguanil should be taken daily until 7 days after the last potential exposure, mefloquine should be taken weekly until 4 weeks after the last potential exposure. The use of mosquito nets, long sleeved clothing and N,N-Diethyl-meta-toluamide, and whether the child sustained insect bites, are important when considering arthropod-borne infections.
Past Medical, Drug and Family History
Current comorbidities and medications, especially those that are immunosuppressive, may predispose the child to infections. A child with splenic dysfunction, for example, sickle cell disease, is at increased risk of malaria and encapsulated organisms such as pneumococcus. Medical care received abroad may be inadequate. Incomplete courses of substandard antimalarials and antibiotics may lead to partially treated infections. Details of unwell travel contacts or companions may have diagnostic and public health implications.
History of Presenting Complaint
A complete systems review, including the date of onset and sequence that symptoms present, is important. Associated symptoms, such as a cough or abdominal pain, may help to localise the infection although symptoms may yet manifest in the acute presentation. The pattern and duration of fever may be important, however, the traditional tertian pattern in Plasmodium falciparum malaria is rarely seen in children. Many infections present with a non-specific fever and a variety of associated symptoms. Care must be taken particularly in the acute phase that associated symptoms do not lead to misdiagnosis through inappropriate localisation of the infection.
Examination
A complete physical examination is important to elicit signs associated with certain infections. This should include an assessment of the child's weight and nutritional status. However, the absence of associated signs and symptoms does not necessarily exclude diagnoses. Skin rashes are often non-specific, but may be characteristic of specific infections or indicate potentially serious infection, such as the petechiae/purpura of meningoccocal disease and viral haemorrhagic fevers (VHF). Lymphadenopathy, hepatomegaly, splenomegaly and jaundice are each associated with a variety of infectious and non-infectious causes (Table 1).