Antidepressants Blog

Evaluation of the febrile traveler should include careful documentation of the associated symptoms and signs, since these can help guide the clinician toward the correct diagnosis. The mode of onset of the illness (acute versus gradual) and the precise sequence of symptoms should also be ascertained.
A thorough physical examination must also be performed to elicit additional clues.

Vitals Signs
Although rarely diagnostic, determination of a fever pattern may be helpful. Several fever patterns have been identified. However, it is logistically difficult to obtain accurately recorded temperatures, and the administration of antipyretics interferes with this task. In particular, although fevers every 48 to 72 hours are typical of malaria, these characteristic cyclical fevers are rarely seen in travelers, since they are much more likely to occur in a relapse of malaria rather than an initial infection. A pulse rate that is slow for the degree of fever (pulse-temperature dissociation) may suggest typhoid fever or rickettsial infections.

Skin
Many febrile patients have a rash that can assist in the diagnosis. A maculopapular rash may be seen with many travel-related infections, notably dengue fever, leptospirosis, and typhus, as well as with acute human immunodeficiency virus and acute hepatitis B. A drug eruption should also be considered in the differential diagnosis of a maculopapular rash. Rose spots, crops of pink macules (2 to 3 mm in diameter) on the chest or abdomen, suggest typhoid fever. An eschar, a black necrotic ulcer with erythematous margins, may be found with many rickettsial diseases. Dengue fever, meningococcemia, Rocky Mountain spotted fever, and viral hemorrhagic fevers may present with petechiae, ecchymoses, or hemorrhagic lesions.

Eyes
The eyes should be examined for evidence of conjunctivitis (consider leptospirosis) or retinal hemorrhages (consider subacute bacterial endocarditis).

Sinuses, Ears, and Teeth
These are common sites of occult infection, and attention to these areas can help to avoid unnecessary testing for other causes of infections.

Heart and Lungs
Auscultation of the lungs should focus on the detection of inspiratory crackles and wheezes, and auscultation of the heart is performed to evaluate for the presence of a murmur, since subacute bacterial endocarditis is always a major consideration.

Abdomen
The presence of splenomegaly should be determined, since this is associated with a number of diseases, notably mononucleosis, malaria, visceral leishmaniasis, typhoid fever, and brucellosis.

Lymphadenopathy
Localized lymphadenopathy may be seen in many infections, and its presence is often less helpful than other signs. Generalized lymphadenopathy, however, has a more limited differential diagnosis, and this finding may be more useful.
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Congenital heart disease refers to defects of the heart that are present at birth. About 6 to 8 babies out of every 1,000 who are born alive have a congenital heart defect.
When you consider that 3 weeks after conception the heart consists of a tiny tube that folds, fuses, excavates, and molds itself so that all of its basic structures are present by the eighth week of development, it is more amazing that things turn out right as often as they do.
If your child has a congenital heart defect, you probably have many questions. What exactly is wrong? How did it happen? How will it affect your child’s life? What can be done about it? Your doctor will answer these questions specifically as they relate to your family, but this section provides a general background to help you understand the information.
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Pre-travel immunizations and chemoprophylaxis taken during travel must be determined, since these will influence the probability of acquiring infections. These interventions vary in efficacy. The proper administration of vaccines against hepatitis A, hepatitis B, and yellow fever effectively rules out each of these infections as a cause of a patient’s illness. However, vaccines against typhoid fever or use of immunoglobulin for the prevention of hepatitis A is only 70% to 80% effective, so these infections should still be considered among patients who have been immunized. Childhood immunizations against diseases such as polio, diphtheria, and measles may not provide adequate protection in adults unless a booster has been administered or natural disease reported. Immigrants from developing countries may not have received routine immunizations.
For travelers to malaria-endemic areas, the use of personal protective measures (insect repellents, bed nets) and chemoprophylaxis must be assessed. Note that no antimalarial chemoprophylactic regimen is completely protective. Furthermore, poor compliance with antimalarials among travelers is a well-documented cause of failure.
The health of the patient prior to travel is also of importance. The presence of underlying medical conditions (cardiopulmonary diseases, immunosuppression, asplenia) may increase susceptibility to various infections. Knowledge of the medications taken for treatment of a patient’s illness prior to and during travel is also essential, since these may alter the presentation of certain diseases.
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