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Fever in the returned traveller (NPS 2/2012) recommended - copy
Manual of Travel Medicine, Australia Dec 2011
see also http://www2.ncid.cdc.gov/travel/yb/utils/ybBrowseO.asp
RETURNED TRAVELLER - Summary (Full sheet)
- Africa - schistosomiasis
- Africa, PNG, Solomon Islands, Vanuatu - Malaria
- Exposure risk - contaminated food & water, insect bites,
- Risk increases with length of stay, remote area travellers
Febrile Illness - refer immediately if unwell
- Malaria until
- Typhoid Fever & Dysentery
- Viral Hepatitis ( A to E )
- Others: pneumonia, legionnaires, septicaemia (meningococcal, staph, strep, meliodosis)
gonorrhoea, chlamydia, leptospirosis, Q fever, typhus, acute HIV.
- Thick and Thin Blood films 12 hrly x 3 - one negative blood film does
not exclude malaria
- If thrombocytopaenia there is a high chance of malaria -
Diarrhoeal Illness - (NB. could still be malaria)
- Bacterial - Enterotoxigenic E. coli (ETEC) account for >80% of cases, Less common - Campylobacter,
Salmonella, Shigella, Yersinia, Aeromonas
- Single Faeces M & C usually will detect these (Nb. ETEC not detected
with routine culture)
- Treat Norfloxacin 800mg stat then 400mg BD for 3 days or Azithromycin (To hospital if unwell)
- Parasites -
Giardia most frequent (Treat with Tinidazole 2 g orally stat)
Less common but important: - Entamoeba histolytica, Hookworm, Strongyloides,
Schistosomiasis, Cryptosporidium, Clostridium difficile and Vibrio cholera (especially if
- Stools M & C x 3 (ask for microscopy for tropical parasites - should also include immunoassay for Giardia & Crytosporidium antigens)
- Persisting diarrhoea: collection of faeces using preservative may
detect D.fragilis parasite
- FBE may show eosinophilia (NB. giardia, amoebae and helminths (tapeworms, adult ascaris)
DO NOT cause eosinophilia.)
consider empirical therapy according to exposure
- mebendazole 100mg BD 3 days - roundworm.
- praziquantel - schistosomiasis, fasciola (drug is easy and
safe to use).
- Albendazole,: - ascaris,hookworm, strongyloides (drug has
high toxicity; therefore pursue diagnosis actively).
- Ivermectim - onchocerciasis & strongyloides
- Tinidazole 2g daily 3 days (amoebic dysentery) or metronidazole 400mg three times a day
for 10 days. cure rate > 95%
For cyst carriers add diloxanide furonate 500mg three times a day for 10 days after
Schistosomiasis - An increasing illness amongst travellers & often asymptomatic
- Geography: -
North & Central Africa particularly Sub-Saharan Africa
- Egypt & Gulf states (Saudia Arabia, Iran, Iraq, Syria, Turkey)
- India, China, Indonesia, Philippines, Thailand, Cambodia, Laos, Japan
- South America
- Symptoms: - Acute
febrile illness (Katayama Fever) often with urticarial rash.
- Cercarial Dermatitis ( a common self limiting illness with itchy papules lasting a few
days - symptomatic treatment only is required.)
- Chronic Fibro inflammatory disease occurs after many
years if untreated.
- Investigations: - Serology for all returned travellers from Africa and other risk areas who swam, waded or walked in
streams or lakes. Schistosoma eggs can be ingested via contaminated water.
- Check for Eosinophilia.
- Other tests include Faeces for eggs & Terminal urine x 3 for microscopy
nb. Serolgy is often negative with the early Katamaya fever and eggs do not appear until
- Consider Empirical treatment:
- Treatment: Praziquantel 40mg/kg/d for 3 days gives
95% cure rate with no relapses. Eosinophilia often takes
6 months to reduce and may actually rise soon after treatment.
Serological tests of value
- Schistosomiasis: early seroconversion within weeks
but may be delayed for up to 3 months
few false negatives after 3 months
some false positives occur
- Amoebiasis: highly specific.
sensitivity:- extra intestinal disease - 95%
invasive intestinal disease - 85%
asymptomatic carrier - 10%
- Strongyloides: sensitivity & specificity - 80-90%
(in comparison, stool microscopy = 80% sensitive)
- Filariasis: up to 30% false positives
low positive results difficult to interpret -Treat: diethyl carbamazine
- Hydatid: sensitivity:
active liver cysts 90%
dead/calcified cysts 50%
specificity: - poor at low titre IHA
good at high titre IHA
- HIV: most positive by 3 months
if high risk check at 6 & 12 months
Information mostly taken from: "International
Travel and Health" (WHO year book -
Australian Immunisation Handbook, 8th Edition - 9/2003 - Part1 - Part 2 & Part 3 (large pdf
Centre for Disease Control, USA - www.cdc.gov/travel Travel Health Seminar Oct 96, June 97,Feb 98, March 99, May 2000, August 2002 &
March 2005 - Victorian Medical Postgraduate Foundation.
Manual of Travel Medicine,
Melbourne, Oct 2004.
Updated 06/09/2006. Additional references & disclaimer.