How to navigate the complexities of a travel-related fever diagnosis

Fever after international travel can be a diagnostic puzzle, often involving a wide range of infectious and non-infectious possibilities. With global mobility increasing, practitioners are seeing more cases that require careful evaluation and specialized testing.

In this case, a practitioner seeks insights on a travel-related fever diagnosis, highlighting which differentials to prioritize and which advanced diagnostics can help uncover the underlying cause. Have you diagnosed a travel-related fever before? Log in or sign up to share your approach and see the consensus.

Background: A 40-year-old man presents with 10 days of fevers, night sweats, and weight loss after returning from a rural trip to sub-Saharan Africa. The exam reveals mild hepatosplenomegaly without rash or lymphadenopathy. Labs show anemia, elevated ESR, and mildly decreased platelets. Blood cultures and initial malaria smears are negative. CXR is normal. He has no chronic medical conditions and received routine travel vaccines.

Questions for consult 

 Consults

Key takeaways about diagnosing a travel-related fever:

• Malaria remains a top priority—even with negative initial tests
  Despite negative smears, malaria is the leading differential diagnosis, and it is recommended to repeat testing with rapid diagnostic tools to avoid missed cases.
  
• Broaden the differential beyond the usual suspects
  Consider a wide range of infectious and non-infectious etiologies, including visceral leishmaniasis, typhoid fever, HIV, TB, arboviruses, and zoonoses like brucellosis and leptospirosis.
  
• Ongoing patient contact is critical to timely diagnosis
  Maintain communication with the patient, especially when dealing with complex or travel-related illnesses. Delays in follow-up can lead to missed testing opportunities and slower diagnosis, making continuity of care essential.
  

Family Practice

"Given this patient’s subacute febrile illness with hepatosplenomegaly, anemia, and recent travel to sub-Saharan Africa, priority differentials include malaria (despite negative initial smears), visceral leishmaniasis, typhoid fever, and acute HIV. Advanced diagnostics should include repeat malaria smears and RDT, Leishmania serology or PCR, HIV testing, and possibly bone marrow biopsy to evaluate for leishmaniasis or HLH."

Allergy/Immunology

"Malaria and yellow fever are both possibilities. I would start with a complete blood count and differential with review of peripheral blood smears to help establish a diagnosis."

Family Practice

"Repeat malaria testing, as well as getting more detailed travel, history, and exposures.
Likely refer to ID to make sure all appropriate testing is performed. I would also look up some of the more common travel-related illnesses. Most importantly, it is not to lose contact with the patient, which could delay testing and diagnosis."

Nephrology

"In a patient with prolonged fever, constitutional symptoms, and hepatosplenomegaly after traveling to sub-Saharan Africa, a broad range of infectious diseases must be considered, including parasitic, bacterial, and viral etiologies. The negative initial blood cultures and malaria smears do not exclude these possibilities, and more advanced testing is required. Non-infectious causes, such as malignancy, are also in the differential."

Family Practice

"While malaria is certainly high on the list, other thoughts can be sepsis, tuberculosis (TB), HIV coinfections, and bacterial zoonoses such as brucellosis, leptospirosis, and Q fever are common.

Viral Infections, including arboviruses like dengue and Zika, are important causes of febrile illness. Hemorrhagic fever viruses can also be a factor. Parasitic Infections: Malaria, although overdiagnosed, is still a cause of fever. Zoonotic Diseases: Infections passed from animals to humans, such as those caused by rickettsiae (causing spotted fever and typhus), can be prevalent."

If you have an opinion on how this practitioner should approach making a diagnosis, review the full case on Healthcasts and share a consult.