FEVER IN A RETURNING TRAVELLER
History
Michael is a 7-year-old boy brought to the A&E department by his father at 10pm. He has had an intermittent fever and backache for the last 48 hours, has vomited three times, had two loose stools and an episode of violent shivering this evening. He was previously healthy, except for frequent abdominal pain during the last school term, not associated with any change in bowel habit. His parents are originally from Nigeria, although he was born in this country. He has frequently travelled to Nigeria in the summer holidays and returned from his most recent trip 1 week ago. He has received all his routine immunizations according to the UK schedule.
Examination
He looks flushed and withdrawn. His heart rate is 130 beats/min, capillary refill is less than 2 s, respiratory rate 40/min, oxygen saturation 97 per cent in air, and temperature is 39C. He has no murmurs, breath sounds are normal throughout the chest, he is uncomfortable on abdominal examination, but has no guarding or rebound tenderness. Ears, nose and throat are unremarkable. There is no obvious rash, no lymphadenopathy and no evidence of jaundice.
INVESTIGATIONS
Normal
Haemoglobin 11.5 g/dL 11.1–14.7 g/dL
White cell count 17.3 109/L 4.5–14.5 109/L
Platelets 57 109/L 170–450 109/L
C-reactive protein 53 mg/L 5 mg/L
Sodium 133 mmol/L 135–145 mmol/L
Potassium 4.1 mmol/L 3.5–5.6 mmol/L
Urea 2.7 mmol/L 2.5–6.6 mmol/L
Creatinine 42 µmol/L 20–80 µmol/L
Questions
• What other investigations are essential in this child?
• What are the differential diagnoses?
• What further history is important?
• What is the treatment?
Medicine
In any traveller returning from a malaria endemic area, it is absolutely essential to do an urgent thick blood film to look for malaria parasites, and many hospitals now also use a rapid diagnostic test kit to identify the presence of malaria antigens in the blood. It is also important to obtain blood cultures, liver function tests, urine dipstick and, in view of this patient’s tachypnoea, a blood gas sample (to look for acidosis) and possibly a chest X-ray. Michael’s blood film showed 1 per cent parasitaemia with Plasmodium falciparum and the rapid diagnostic test was positive. Malaria cannot be diagnosed or excluded on clinical grounds, and may coexist with other infections. Blood films must be done and three negative films are required to exclude the diagnosis. Thrombocytopenia is commonly seen in malaria, but cannot be relied upon to make the diagnosis.
Non-specific symptoms occuring in children with malaria
• Fever
• Diarrhoea
• Vomiting
• Cough
• Tachypnoea
• Headache
• Lethargy
• Coma
• Jaundice
• Haematuria
• Myalgia • Pallor
The differential diagnosis of fever in the returning child traveller can be very wide, including haematuria, malaria, typhoid and all of the causes of childhood fever in their home country (e.g. tonsillitis, myalgia, pneumonia, urinary tract infection, etc). Frequently the cause of the fever is not an unusual or exotic infection at all, even if it was acquired abroad. An adequate travel history includes details of exactly where the child visited (especially whether urban or rural), what sort of accommodation they stayed in, what activities they did during their visit, and what immunizations and malaria prophylaxis they had. Michael did not take any prophylaxis because his parents felt malaria was not a serious illness. Treatment should be started promptly, guided by advice from an expert in infectious diseases. A variety of oral treatment options are available for uncomplicated malaria, but intravenous quinine remains the standard treatment for severe disease. Broad-spectrum antibiotic cover should also be given in the case of a seriously unwell child.
KEY POINTS
• Fever in a traveller returning from a malaria-endemic area is malaria until proven otherwise.
• Non-specific symptoms should not be interpreted as ruling out the diagnosis.
• Prompt initiation of treatment is essential.
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