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.
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.
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.
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.
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.
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.