Article Figures & Data
Figures
- Figure 1.
Maculopapular rash with diffuse petechiae and areas of bruising associated with dengue hemorrhagic fever. Photo courtesy of the Emerging Infectious Diseases journal. Reprinted from http://www.cdc.gov/EID/content/14/8/1329-G.htm.
- Figure 2.
Cutaneous larva migrans. A and B: Typical elevated lesion caused by the migrating parasite on the plantar surface of the foot. C: Ulcerative lesion at site of origin on the lateral side of the foot. Photo courtesy of the Emerging Infectious Diseases journal. Reprinted from http://www.cdc.gov/eid/content/15/11/1856-F.htm.
Tables
Travel history Often, a given condition is found only in a particular geographic region or has a specific incubation period. For example, a febrile child who presents 3 days after returning from a week in Rio de Janeiro during Carnival has a low likelihood of having malaria (low-risk setting, lower end of the incubation period) but a reasonable chance of having dengue (high-risk setting, correct incubation period). Physical examination Focuses on signs associated with tropical illness, such as splenomegaly (malaria, typhoid) or rash (dengue). Differential diagnosis Associated with travel Conditions tropical in nature, or otherwise nonendemic to home region Not associated with travel As an example, a child who develops fever, rash, and hypotension a few days after return from a week-long holiday in El Salvador could have dengue acquired in El Salvador, among other diagnoses, but could also have rickettsial disease, adenovirus, or other illness acquired at home before travel A commonly used rule of thumb is the longer from travel symptoms present, the less likely they are to be associated with travel, although some conditions, such as vivax malaria, may present months after return from the tropics Diagnostic evaluation Driven by the differential diagnosis Gives clues (thrombocytopenia plus hyperbilirubinemia commonly seen with malaria; leukopenia with typhoid, dengue, and other infections) or looks for specific etiologies themselves (malaria smear, Entamoeba histolytica antigen) Treatment and/or referral Allow for definitive resolution of the presenting issue - Table 2.
Incubation Periods for Selected Infections Responsible for Fever in Children Who Have Returned from the Tropics
Incubation Period (days) Infections ≤14 Dengue Malaria* Yellow fever Chikungunya Typhoid fever† Rickettsial infections‡ Leptospirosis§ 15 to 30 Malaria* Typhoid fever‡ Leptospirosis§ Hepatitis A and E| Visceral leishmaniasis Acute schistosomiasis (Katayama fever)¶ Tuberculosis >30 Malaria* Hepatitis A and E‖ Acute schistosomiasis (Katayama fever)¶ Visceral leishmaniasis Tuberculosis * Most Plasmodium falciparum infections have an incubation period of 7 to 30 days (average, ∼10 days); Plasmodium vivax and Plasmodium ovale may present late, months or even years (rarely) after infection.
† Average incubation period of typhoid is 14 days, but can vary from <7 to >21 days. Incubation periods of >30 days are quite rare.3
‡ Most rickettsial infections have incubation periods of <14 days.3
§ Leptospirosis has an average incubation period of 1 to 2 weeks; rarely, leptospirosis may present >14 days after infection.
‖ Hepatitis A and E have an incubation period of 2 to 6 weeks; jaundice is usually seen.
¶ Acute schistosomiasis typically presents >4 weeks after exposure to fresh water in the tropics.
- Table 3.
Management of Common Skin Conditions Presenting after Travel to Developing Countries
Condition Presentation Treatment/Management Cutaneous larva migrans44 Although rash will heal spontaneously within a few weeks, the unpleasant cosmetic appearance and substantial itching usually dictate treatment Albendazole (400 mg single dose) Ivermectin (200 mcg/kg single dose) Dog bites/minor trauma Management of potential rabies after exposure, as indicatedTopical antibiotic, as indicatedOral antibiotic if cellulitis is present Superficial skin infections Topical vs oral antibiotic, as indicated Cutaneous Leishmaniasis43,46 Can have severe sequelae, including destructive mucosal disease with some New World strains Some therapeutic agents can be difficult to obtain in some industrialized settingsAlthough topical paromomycin may be effective against some Leishmania strains with very low potential for mucosal spread, prolonged parenteral therapies may be necessaryConsider referral to an expert in tropical medicine/infectious diseases Myiasis45 Tumbu fly (sub-Saharan Africa)Bot fly (Central and South America) Place petroleum jelly over the larva's communication to the skin. Larva will then protrude from the lesion and can be removed with forcepsBot fly larvae anatomy make simple removal more difficult than for Tumbu fly, yet the above technique may be attempted. Often lidocaine infiltration followed by removal through incision is necessary Scabies46 Usually responds to topical permethrin (5%)Lindane should be avoided in young childrenOral ivermectin (200 mcg/kg single dose) is an alternative therapy Exclude nonparasitic causes of eosinophilia Drug reaction, asthma, and urticaria; these are often apparent from history and during examination3 Initial work-up Stool samples for ova and parasites: at least 3 samples obtained from 3 different days Should detect common parasitic causes, such as Ascaris and hookworm, and may detect Strongyloides and schistosomiasis, as well52 Serologies (per clinical and epidemiologic likelihood) Often necessary for diagnosis of strongyloidiasis and schistsomiasis, and other, more rare parasitic causes of eosinophilia in returned travelers, such as cysticercosis, echinococcosis, toxocariasis, and trichinellosis, among others52 Less useful for filariasis, in which marked eosinophilia is generally present only in the early stage of infection53 Fresh water exposure Serology may not be positive until 3 months or more after exposure3 Specificity 99% for all Schistosoma strains Sensitivity 99% for S. mansoni, but may be less than 50% for S. japonicum and S. hematobium Management of eosinophilia Can be difficult to make a specific parasitic diagnosis Schistosomiasis or strongly suspected schistosomiasis can be treated with praziquantel Often, nonschistosomal eosinophilia will resolve with an empiric 5 to 7 day course of albendazole, reflecting its generally helminthic nature52 Consultation with a tropical medicine specialist advised when aspects of diagnosis and management of eosinophilia are unclear - Table 5.
SORT Recommendations54 for the Evaluation and Treatment of a Child Who Presents as Ill after International Travel
Recommendation SOR* Malaria may develop even when antimalarial prophylaxis has been properly taken. It must be excluded in any ill, febrile child who has traveled in a malaria-endemic zone in the year during presentation. A Nonsevere dengue is self-limited and care is supportive, whereas severe dengue (heralded by hemoconcentration—rising hematocrit or thickening of the gallbladder wall on ultrasound) requires hospitalization and intensive management focused on early recognition and treatment of shock. A Most traveler's diarrhea in children is caused by bacteria, but in children younger than age 2, viral etiologies may be more common, as may atypical and/or prolonged episodes of traveler's diarrhea. B Noninfectious etiologies should be considered when diarrhea persists and repeated investigations for infection are negative. A An child who appears ill and who has a rash (particularly if petechial or hemorrhagic) in association with fever should receive a priority work-up focused on ruling out serious conditions. C High absolute eosinophil counts (>1,000) in a returned pediatric traveler are predictive of parasitic infection, particularly with stays in the tropics of more than 3 months. B * Strength of recommendation (SOR): A, good-quality patient-oriented evidence; B, inconsistent or limited-quality patient-oriented evidence; C, consensus, usual practice, opinion, disease-oriented evidence, case series.
