Fever in the returned traveller (child)

• https://www.rch.org.au/clinicalguide/guideline_index/Fever_in_the_recently_returned_traveller
• https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Fever-Returned-traveller

Key Points

• General: Most infections are mild or self-limiting but can be challenging to distinguish from serious infections due to non-specific presentations.
• Malaria: Falciparum malaria is the most common serious infection and cause of death.
• Respiratory Infections: Severe respiratory infections from novel viral infections (e.g., COVID-19, H5N1) require vigilance as travelers can act as sentinels, carriers, and spreaders.
• Drug-Resistant Infections: May have been acquired, especially if hospitalized.

Background

• Common Diseases: Diseases unrelated to travel are more likely than exotic ones acquired overseas.
• High-Risk Groups: Travellers visiting friends and relatives are more likely to have a serious illness upon return.
• Febrile Child Considerations: Consider non-infectious causes (e.g., DVT/PE). Possible infections:
  • Common childhood infections.
  • Infections from endemic regions.
  • Infections from regional outbreaks.

Public Health Importance

• Immediate Measures: Consider disease of public health importance, requiring immediate infection control and containment.

Specific Precautions

• Measles: Nurse in a negative pressure room with airborne precautions.
• Novel Respiratory Illness: Use appropriate precautions.
• Haemorrhagic Fevers: Strict isolation and barrier nursing.

Differential diagnosis

Infection	Incubation Period		Clinical Features
Malaria	Variable	P. falciparum: 7 days – 12 weeks. Other malarial species: weeks to several years.	Fever, malaise, headache, nausea, vomiting, hepatosplenomegaly, anaemia. Refer to the Malaria – ED guideline.
Typhoid (Salmonella)	Variable	3 days – 3 months (usually 8-14 days)	Fever headache abdominal pain, altered bowel habit rose spots rare in children.
Rickettsial infection	Variable	3-21 days (depending on type)	Fever myalgia primary inoculation lesion (eschar) ± generalised rash (petechial or macular papular).
Dengue	Short	3-14 days (usually 5 days)	Fever + 2 of: – myalgia – retro-orbital pain – arthralgia – headache – leucopenia – haemorrhagic manifestations
Chikungunya	Short	1-12 days (usually 3-7 days)	Arthralgia myalgia headache nausea rash.
Influenza	Short	1-5 days (usually 2 days)	Fever URTI/LRTI myalgia
Campylobacter	Short	1-10 days (usually 3 days)	Fever diarrhoea vomiting abdominal pain bloody stools.
Shigella	Short	12 hours – 7 days (usually 2 days)	Fever diarrhoea vomiting abdominal pain bloody stools.
Measles	Intermediate	7-18 days (usually 10 days)	Cough coryza conjunctivitis, rash.
Viral haemorrhagic fever (Ebola)	Intermediate	2-21 days (usually 8 days)	Fever, fatigue headache gastrointestinal signs, rash petechiae mucosal bleeding
Leptospirosis	Intermediate	2-26 days (usually 10 days)	Headache myalgia vomiting, rash abdominal pain conjunctival suffusion.
Hepatitis A	Long	2-7 weeks (usually 30 days)	Vomiting abdominal pain jaundice.
Rabies	Long	3-8 weeks (sometimes years)	Animal bite: – tingling at the site – fever – myalgia – headache – neurological symptoms. Note – bites are more likely to be infected with animal oral flora than Rabies.

Incubation periods
Short <10 days	Intermediate– 10-21 days	Long >21 days
Malaria (P. falciparum)	Malaria (P. falciparum)	Malaria (P. vivax, P. ovale)
Typhoid (S. typhi or S. paratyphi) (usually 8-14 days)	Typhoid	Typhoid
Rickettsial infection	Rickettsial infection	Hepatitis
Arboviral infections, eg Dengue, Yellow fever	Measles	Rabies
Viral haemorrhage fever	Viral haemorrhage fever	Amoebic liver abscess
Influenza	Q fever	Tuberculosis
Campylobacter		Filariasis
Shigella		HIV
Chikungunya

Assessment

History

• Travel Details: Location, type, timing, duration.
• Exposure Risks: Contact with animals, insect bites, water/food sources, activities, sick contacts.
• Immunisation: Routine and travel-specific vaccinations.
• Prophylaxis: Medication use, adherence, mosquito nets/insect repellent.
• Symptom Details: Onset, duration, course.
• Healthcare While Away: Any medications taken.

Travel history checklist
Clinical syndrome	Timing, pattern and duration of symptoms .Did you seek medical care while overseas?  Did you take any medications, over the counter/supplements/herbs? Where were these medications acquired: Australia or overseas?
Geographic exposures	Countries travelled to, and transited through? What regions or cities specifically were visited?Include travel dates and duration of travel to establish possible incubation period.
Other exposures	What did you do while travelling? Any exposure to rural/forest/farm/water areas?  Any animal exposure, especially scratches/bites/patting? What did you eat? Was water sterilised? Did anyone have gastroenteritis symptoms while travelling? Any undercooked meat or unpasteurised dairy? Insect bites (mosquitos, sand flies, ticks etc.)Any unwell contacts while you were travelling? (e.g. relatives with a cough)
Vaccination status and malaria prophylaxis	Has the child had routine vaccinations per schedule? (Check the Australian Immunisation Registry [AIR] for confirmation). Note that some vaccine-preventable diseases e.g. measles, are more prevalent overseas. Did the child have any extra vaccinations before travel? If so, what, and when? Note that some travel vaccines, e.g. typhoid, offer incomplete protection Was any malaria prophylaxis taken? If so, which agent, when was it taken, assess adherence, and when it was ceased? What about other strategies? (bed nets, insect repellent)

Examination

• Common Findings: Fever, tachypnoea, rash, altered consciousness, haemorrhage, hypotension.
• Specific Clinical Features:
  • Rashes/Lesions: Dengue, typhoid, rickettsial infections, measles.
  • Eschar: Rickettsial infections, borrelia, haemorrhagic fevers.
  • Hepatomegaly: Malaria, typhoid, dengue.
  • Splenomegaly: Malaria, typhoid, mononucleosis.
  • Acute Abdomen/GI Haemorrhage: Typhoid.
  • Respiratory Symptoms: Respiratory viruses, measles.
  • Jaundice: Viral hepatitis, measles.
  • Lymphadenopathy: Rickettsia, toxoplasmosis.
  • Petechiae: Meningococcal disease, haemorrhagic fever.
  • Altered Conscious State: Cerebral malaria, meningitis.
  • Persistent Fever: Malaria, enteric fever.
  • Late Onset Fever: Plasmodium vivax, hepatitis.

Clinical Features Specific to Infection
Clinical Features	Infection or disease implicated
Rashes/skin lesions	Dengue, typhoid, rickettsial infections, measles, leptospirosis, syphilis, gonorrhoea, brucellosis, chikungunya
Eschar	Rickettsial infections, borrelia, Crimean-Congo haemorrhagic fever
Hepatomegaly	Malaria, typhoid, dengue, viral hepatitis, amoebiasis, leptospirosis
Splenomegaly	Malaria, typhoid, mononucleosis, trypanosomiasis, brucellosis, dengue, kala-azar
Acute abdomen or GI haemorrhage	Typhoid
Cough, coryza, conjunctivitis	Respiratory viruses, measles
Jaundice	Viral hepatitis, measles
Lymphadenopathy	Rickettsia, toxoplasmosis, brucellosis, HIV, mononucleosis, visceral leishmaniasis
Petechiae	Meningococcal disease, viral haemorrhagic fever, rickettsia
Haemorrhage	Dengue, meningococcaemia, Lassa fever, Marburg or Ebola, Crimean-Congo virus, Yellow fever, Rocky Mountain Spotted Fever
Altered conscious state, lethargy, Meningism	Cerebral malaria, meningitis, African trypanosomiasis
Fever persisting >2 weeks	Malaria, enteric fever, EBV, CMV, toxoplasmosis, acute HIV, acute schistosomiasis, brucellosis, TB, Q fever
Fever with onset >6 weeks after travel	Plasmodium vivax or P ovale, acute hepatitis (B, C or E), TB, amoebic liver abscess

Management

Investigations

First Line Investigations

• Blood culture
• Thick and thin blood film for malaria (EDTA tube) – performed 2-3 times, 12-24 hours apart.
• Rapid diagnostic test for malarial Ag (EDTA tube) – urgent results available 24hr/day.
• Full blood count, liver function tests, electrolytes, urea & creatinine
• Serum to store
• Urine microscopy, culture, and sensitivity (MC&S)

If Severely Unwell

• Coagulation profile, glucose
• Meningococcal and pneumococcal PCR (EDTA tube)
• Consider lumbar puncture
• Carbapenemase resistance screening (CRE) and extended-spectrum beta-lactamase (ESBL) screening: rectal swab or stool specimen

Further Specific Investigations Based on History and Clinical Presentation

• Arbovirus Risk Areas:
  • Serology for dengue/arboviruses (+ dengue NS1 Ag in the 1st week of illness) (red/gold top)
  • Chest X-ray +/- nasopharyngeal aspirate for respiratory viruses
  • Stool bacterial culture, faecal ova, cysts, and parasites (O/C/P) and enteric viruses
• Endemic Measles or Measles Outbreak:
  • Measles PCR on nasopharyngeal aspirate/urine in suspected cases
• History of Hospitalisation Outside WA within Last 12 Months and Admission:
  • Multi-Resistant Organism (MRO) screening
  • 2 rectal swabs or 1 stool specimen (CRE, ESBL, VRE)
  • 1 nose and 1 throat swab for MRSA
  • Swab of both axillae and groins (Candida auris) if admitted to hospital outside Australia

Investigation Based on Clinical Syndrome
Clinical syndrome	Most important infections to consider	Investigations
Fever alone	Malaria* Typhoid Dengue Hepatitis A	FBE thick and thin film* Blood culture LFT if jaundiced BGL Serum to store (Specific tests should be discussed with Infectious Diseases team)Other tests to consider depending on most likely pathogens:measles serology +/- throat or nose swabs for PCRurine microscopy and cultureCSF microscopy and culture in severely unwell patients with meningism, encephalopathy or seizures (after consideration of need for further neuroimaging first)
Fever + diarrhoea	Malaria* Typhoid Dengue Hepatitis Travellers’ diarrhoea** Cholera Dysentery (bloody diarrhoea)	As for fever alone plus Stool MCS + OCP (latter, particularly if prolonged >10 days)
Fever + respiratory	Malaria* Pneumonia Influenza Tuberculosis (TB)	As for fever alone plus CXR Swab for respiratory viruses, including influenza and COVID If Tuberculosis considered, discuss investigations with Infectious Diseases team

Treatment

• Outpatient Management: Most children will not require empiric treatment.
• Empiric Therapy: In sick children, may include sepsis, malaria, typhoid treatments. Refer to specific guidelines and discuss with Infectious Diseases team when necessary.

Admission

• Primary admitting team: General Paediatrics
• Consider Infectious Diseases Consultation

Severely Unwell Patient

• Refer to the Serious Illness Assessment
• Prioritise blood culture and malaria rapid testing.
• Treatment:
  • Malaria positive – refer to Malaria– ED guideline.
  • See empiric antibiotics as per Sepsis and Bacteraemia – ChAMP Guideline (internal WA Health only)