The approach to the patient with fever from or in the tropics

The approach to the patient with fever from or in the tropics

Febrile illness is common in the tropics, or after travel tothe tropics. The causes encompass infectious and noninfectiouscauses. Infections include those peculiar to tropicalregions and those common worldwide (such as urinarytract infection, pneumonia)Clinical featuresA detailed history is essential. This should include accuraterecording of the dates of travel, duration of stay andcountries visited, with information on the places involved(cities, rural areas, beach resorts etc.) and the reasons fortravel. Information about sexual contact during travel isalso important. The history should also include detailsof vaccination prior to travel and malaria prophylaxis,with some assessment of the regularity of takingprophylaxis.The chronology of events should be recorded, particularlynoting the interval between the end of the patient'stravels and the onset of illness where this has occurredafter leaving the tropics. This gives an idea of the incubationperiod of the disease. Physical examinationshould pay attention to the presence of skin lesions,oral lesions, jaundice, adenopathy, hepatosplenomegaly,and involvement of the nervous system. After initialassessment it is vital to reassess the patient at frequentintervals, looking for the appearance of diagnostic symptomsand signs. Antimalarial chemoprophylaxis should bediscontinued while investigation is proceeding as it maysuppress parasitaemia and prevent diagnosis of malaria

Investigations The investigations performed will depend on the clinicaldiagnosis or the differential diagnosis. Blood films should be examined daily for malaria parasitesin any febrile patient who has been to a malarialarea until either a diagnosis is made or the fever resolves.Blood films may also be examined for trypanosomes ina patient who has been in rural east or west Africa. Afull blood count is useful for looking for leukocytosis(suggesting bacterial infections), leukopenia (typhoid,viral infections), pancytopenia (visceral leishmaniasis)or eosinophilia (helminthiasis: schistosomiasis, fascioliasis,visceral larva migrans, clonorchiasis, Bancroftianfilariasis). A Mantoux test should be done early on. Blood cultures should be taken and, if brucellosis is apossibility, kept under observation for up to 6 weeks, asthe organism grows slowly. Serological tests that may be useful include those forsyphilis, leptospirosis, rickettsial diseases, brucellosis,amoebiasis, leishmaniasis, trypanosomiasis, toxoplasmosis,filariasis and schistosomiasis. They should be usedselectively in relation to the clinical presentation and theexposure. A serum sample should be taken on admissionand saved, and a second sample taken 10 days later. Thispair of sera can then be used to look for a change(usually a rise) in titre. Imaging procedures should include a chest X-ray andthe scanning procedures mentioned under PUO are usedas clinically indicated. Liver and marrow biopsy (see PUO above) are also performedwhere there is a clinical indication, with samplescultured for routine organisms, brucella, fungi and parasites,in addition to histological examination of sectionsand microscopy of smears for tubercle bacilli and leishmania. Bone marrow culture may yield S. typhi in apatient who has previously taken antibiotics.ManagementIdeally treatment will follow from the specific microbiologicaldiagnosis of the cause of fever. Occasionally itis necessary to treat the patient for a disease suspected clinicallybut not proven by available laboratory tests. Thismay be treatment for malaria, or typhoid or rickettsialinfection, or tuberculosis in fevers of longer duration.

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