Crack the Case: Fever in a Returning Traveler

February 7, 2025

We are blessed to have a very international patient population at our clinic in Minneapolis, helped by the Twin Cities reputation as a safe and supportive place for immigrants, refugees and asylees. With roots abroad, many of our families frequently travel home, where infectious disease exposures carry a unique profile compared to that of the U.S. It is therefore not surprising that having a returning traveler with fever, especially when ill appearing, can be a stressful trip down infectious disease memory lane. Today’s episode will explore fever in a returning traveler and tools to narrow your differential during these encounters.

Transcript

Welcome to Talking Pediatrics. I’m your host Dr. Kade Goepferd. On our Crack the Case segment, we take real-life patient cases that present to a primary care setting and dissect medical decision-making, evidence-based guidance and associated clinical pearls. It’s a case-based journey of a diagnostic dilemma with Dr. Brian Fate.

Dr. Bryan Fate: So welcome to Crack the Case where today we will be diving into a mysterious case of fever in a returning traveler. I’m Dr. Bryan Fate, a primary care pediatrician at Children’s Minneapolis, and with me today is Dr. Sydney Notermann, one of our outstanding third-year residents from the University of Minnesota. Before saving lives as a pediatrician, Dr. Notermann saved lives as a lifeguard, including rescuing a toddler caught in a wave pool and an adult who suffered a heat stroke. So thank you for your continued service, Dr. Notermann. And my icebreaker question today is what job preceding medical school do you miss the most?

Dr. Sydney Notermann: The job that I miss the most is, before med school I used to do research in sleep medicine and set up all the sleep studies and got to know all the families and it was just really nice getting to know all the kids and their families and connecting that way.

Dr. Bryan Fate: I love sleep medicine.

Dr. Sydney Notermann: Yeah.

Dr. Bryan Fate: Sleep is great. I love sleep too. Mine would be working for the St. Paul Saints in high school. I didn’t have a car, I walked on the train tracks with one of my best friends who worked there. It was very Stand by Me, Midwest vibes. Got to watch innings of baseball and eat spicy gyros, so good times and good to have experiences outside of medicine. And to introduce the case today we are blessed to have a very international patient population at our clinic in Minneapolis, helped by the Twin Cities reputation as a safe and supportive place for immigrants, refugees, and asylees. In a day last week I had families from Ukraine, Guatemala, Ecuador, not to mention our well-established Latinx and Somali communities. With roots abroad, many of our families frequently travel home where infectious disease exposures carry a unique profile compared to that of the US. It is therefore not surprising that having a returning traveler with fever, especially when Ill-appearing, can be a stressful trip down infectious disease memory lane. So today’s episode will explore fever in a returning traveler and tools to narrow your differential during these encounters. So let’s start the case.
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Dr. Sydney Notermann: For our case, we have a seventeen-year-old previously healthy female who presented with four days of high fever, sore throat, cough, shortness of breath, non-bloody vomiting and diarrhea, as well as a facial rash with itchy skin. She also had myalgias, or muscle aches, particularly in her bilateral lower legs and arthralgias, which is joint pain of her bilateral wrists, knees and ankles. Notably, she had traveled for two weeks in Mexico and arrived home within the last 24 hours, then a few days later the fevers resolved and she started to develop new abdominal pain and intermittent headaches with photophobia or difficulty seeing lights and then retroorbital pain, or pain behind her eyes.

At that time she denied any bleeding, so she didn’t have any mucosal bleeding, vaginal bleeding, bloody noses, bloody stools, black stools or blood in her vomit, and then she didn’t have any petechiae or red dots on her skin and then no bruising. At this time she also had been tolerating adequate intake of fluids and normal urine output. So just going to turn this over to you Dr. Fate, what other questions would you be asking just given her presentation and recent travel history?

Dr. Bryan Fate: One thing to point out is that even though you just went to another country, common things are still common and most people coming back have your garden variety, strep, COVID, flu, so don’t miss the common things. But I think when we have some more unusual symptoms, prolonged fever, ill appearance, we need to be getting more of a in-depth travel history because we know that they’re pretty unique infectious diseases that are specific to certain places.

So I think for our seventeen-year-old, I’d want to know exactly what part of Mexico she was in, for how long. I would want to know if she had been to a travel clinic before, so was she on malaria prophylaxis? Had she been vaccinated against things like yellow fever, typhoid? And I would just want a comprehensive review of all of her vaccines because we know that’s how we stay protected the best. So making sure that her vaccines are up-to-date. I would want to know exactly the timeframe of travel because we know that different infections have different times for incubation, which can be helpful. Also, pointing out that most serious infections should present within 30 days, though there are some that are delayed like rabies. And I want to know what was she doing there? Was she getting tattoos? Was she sexually active there? Has she been in caves? Did she get bit by any animals? What kind of food did she eat? Was she visiting family? So what’s the exact nature of the trip and some of those exposure questions that our ID doctors love. So any more history about her travel, exactly?

Dr. Sydney Notermann: Yeah, so she actually was visiting family in Morelos, Mexico and she was fully vaccinated thankfully, but she unfortunately wasn’t able to go to a travel clinic before her travel. And then she doesn’t have any known bites she was aware of and she had not had any previous sexual activity at all. She did go into a cave and swimming in freshwater as well.

Dr. Bryan Fate: No,-

Dr. Sydney Notermann: I know.

Dr. Bryan Fate: … never go into a cave. Well, excellent. To really narrow down, when we’re thinking about tropical medicine and some more atypical infections, I want to point out that the Yellow Book is a fabulous resource for point of care reference and really if we plug in Mexico as a country and then kind of pinpoint to Morelos, first of all, we want to rule out really dangerous things that we know can make kids and adults very sick, so it’s worth pointing out that this is not an area where yellow fever or malaria is typically found. So prioritizing things that make you the most sick. If we read further, we see that there have been varicella and mumps outbreaks as well as hepatitis A, so good that she’s caught up on her vaccines. Moving on to GI diseases, we also see that there have been rare cases of cholera. We all know traveler’s diarrhea, typhoid would be an important one not to miss as salmonella can become a bloodstream infection.

Then we have Giardia, which we all know from swimming in lakes in Minnesota. We have unique tapeworms like taenia solus. Moving on to respiratory, of course there’s COVID, flu, community acquired pneumonia. TB is more prevalent. And then if we really get sick, we’d have to think more about things like fungi and coccidiosis, Legionnaires’ disease. And finally we have our vector borne diseases, which unfortunately all have a lot of overlap, so there’s usually fever, there’s usually rash, flu-like symptoms. So in this department we already talked about malaria, yellow fever, but we also have things like Zika and dengue and chikungunya. And as we know dengue has the break bone, kind of really bad muscle pain, really almost like your bones themselves are being impacted with terrible headaches. Chikungunya has bilateral really significant joint pain and is kind of its calling card almost presenting like a rheumatologic disease.

We have our Rickettsial diseases which can show themselves with sometimes an eschar or a piece of dead tissue where the tick originally bit the patient. And then we also have more unusual things like leishmaniasis, sandfly bites, so they make these kind of painless ring shaped ulcers. I did not know there were sandflies in Mexico, so thank you, Yellow Book. And then leptospirosis also has flu-like symptoms, rash, it can present with really red eyes, almost like having subconjunctival hemorrhages as well as liver involvement too. So we do see some unique profiles to these, but again, there’s a lot of overlaps that makes it challenging. So why don’t we hear more about how your exam was, Dr. Notermann?

Dr. Sydney Notermann: Yeah, so for her exam her temperature was 102 Fahrenheit, heart rate was 80, blood pressure was 106 over 67, respiratory rate 25, her SATs were 98% [inaudible]. Overall, she did look pretty ill-appearing actually. She was hunched over in her chair holding her stomach. For her skin she had a mildly erythematous blanchable rash on her face, on her cheek and she was actively itching her skin. She didn’t have any jaundice and there was no Scleral icterus on this. She didn’t have any joint swelling. For respiratory she had no congestion, her lungs were clear but a little bit diminished at the bases and she had normal work of breathing. For CV, she had normal capillary refill and no murmurs. For abdominal exam, she did have diffuse mild tenderness without distension or rebound or guarding and no hepatosplenomegaly, as well. For neuro, she had normal strength and tone. And reassuring cranial nerve exam, she had normal gait but was a little bit hesitant with her steps, just noting that her legs were aching.

Dr. Bryan Fate: So vitals wise, her blood pressure is a little bit on the low side, but she’s not tachycardic. Her SATs look good. You could of course trend her weight over time, but overall looks stable from that perspective. I think her skin rash, we talked about some of the calling cards for our vector-borne diseases and a pretty nonspecific rash on her cheeks, which doesn’t point me in any particular direction. You mentioned otherwise normal findings in terms of eyes and liver and obviously the abdominal pain sounds a little more concerning. We can think more about things like typhoid and then some of our other GI bugs that might be more unusual. And obviously with her headache and her photophobia, I’d also be worried about meningitis, so of course wanting to make sure that there’s no nuchal rigidity, neurologic changes. It doesn’t sound like that was the case, though she looks pretty sick. Moving on to labs and imaging, wanting to know what your thoughts were at the time [inaudible].

Dr. Sydney Notermann: Yeah, great question. So just with her recent travel and knowing her joint pain and abdominal pain, I think some initial labs that would be good to think about would be a CBC with diff. You could also get a CMP to check electrolytes and her creatinine, just not knowing if she’s truly drinking enough or not. And then bilirubin, as well as liver function tests would be included in the CMP as well.

Then other things to think about would be getting blood cultures, typhoid thankfully would be included in that. And then with her sore throat, we could think about strep, flu, COVID swab as well, just common things being common. And then other thoughts would be maybe a UA or a chest x-ray. However, I think lower likelihood in the setting without any dysuria or higher frequency of urine. And then no increased work of breathing to suggest need for a chest x-ray or focal lung sounds. And then for labs in a traveler, some of the things, especially with her, maybe more concerning presentation to get would be a malaria thick and thin. Unfortunately you do need three negatives to fully rule that out, but thankfully when looking at the Yellow Book it looks like that’s not as high of a concern on our list, so that’s reassuring given the area she traveled to. Other things you could think about would be dengue serology, Zika serology, chikungunya, rickettsia, leptospirosis, PCR, and then stool OMPs as well.

Dr. Bryan Fate: That’s a broad list, hopefully you have some ID friends, but if you don’t, the Yellow Book can help you out a little bit. So I think just to summarize, we have a seventeen-year-old who came in with four days of high fevers, sore throat, myalgias, joint pain, diarrhea and vomiting with an itchy macular papular rash on her face. She had traveled to Mexico for two weeks in Morelos and after she defervesced, she’s had worsening abdominal pain and intermittent headaches that have been getting worse including photophobia and retroorbital pain. Overall, her vital signs look stable, though she is ill appearing and is having worsening abdominal pain on exam.

So I think in terms of our differential, of course we talked about common things like flu, strep and many other viral entities. I think we certainly would think more about things like dengue and chikungunya with her severe muscle pain and headaches and joint pain. Typhoid is not totally off the table, though I wouldn’t likely expect as much of the myalgias and joint pain, though we do know it can go to your bloodstream, hence the blood cultures and you can look quite sick after that. Leptospirosis too, with belly pain and especially worsening, if we saw any signs of liver inflammation, we think more about leptospirosis, about things like hepatitis A. Then there are amoebic abscesses you can get abroad where you need an ultrasound to diagnose that. So pretty fun, wild differential. What happened with her labs?

Dr. Sydney Notermann: Labs are turned notable for normal leukocytes. She had normal hemoglobin. She did have mild thrombocytopenia to 130 mildly, mildly elevated CRP and normal CK. On her CMP her kidney and electrolytes markers were normal, but she did have elevated liver enzymes with an ALT of 725, AST of 312, and GTT is 77. She had normal alk class and bilirubin, thankfully, and then normal coags as well. They did get a chest x-ray which was read as normal, thankfully. And a COVID, RSV, flu and strep were all negative as well. For her stool, they did take a stool PCR, which was pending at the time. And then they sent travel-specific labs as well including malaria, smear, chikungunya, dengue, rickettsia and Zika. However, all those are send-out labs, so it takes some time to come back unfortunately.

Dr. Bryan Fate: So also something to be aware of is a lot of these more exotic labs, you’re not going to know right away and you have to plan accordingly. And a lot of them it’s supportive care too, but obviously malaria and some other ones have specific treatment. I think with those labs, the call-outs would be her thrombocytopenia, though she doesn’t have petechiae and her coags are normal, and then pretty markedly elevated liver enzymes. We talked about some other causes for liver inflammation. And with that picture we do see that profile with dengue in terms of the degree of inflammation and the thrombocytopenia. And we talked also about things like leptospirosis and hepatitis A and typhoid also being on that list or just some crazy virus that we don’t know how to identify is always on the list too. What happened with her?

Dr. Sydney Notermann: Yeah, so just given her worsening abdominal pain and headaches and her higher fevers in the setting of the recent travel, it was decided to admit her to the hospital just to closely monitor her with ID consulting thankfully. And then dengue IgG and IgM actually came back both positive, so concerning, yes. So concerning for an acute infection of dengue, and given her thrombocytopenia and elevated liver enzymes, we wanted closer monitoring given that possibility to the progression to the very rare but more severe second phase of dengue. So that first phase is more of the higher fevers, the thrombocytopenia, leukopenia you can have with that and transaminitis, you can have the lymphadenopathy, hepatomegaly and the macular papillary rash as well.
Once that fever subsides is when we can be more worried about that second phase of dengue, which can be the hemorrhagic or critical phase, which can lead to shock or organ impairment with elevated liver enzymes. And you can have AKI with that as well as CNS involvement potentially. But thankfully she did not go into that phase because it is super rare. It is more common unfortunately in the second infection. So if you were infected with dengue before and then went traveling again and got it a second time, you’d be at more risk of that second phase unfortunately, so we did give her some extra caution in terms of that as well.

Dr. Bryan Fate: So definitely important if someone does get dengue that you really counsel on mosquito protection because the second time you get the infection, you’re at a higher risk of entering that critical phase. So she did well it sounds like Dr. Notermann?

Dr. Sydney Notermann: Yeah. Yeah, so they monitor her labs in the hospital and they down trended, thankfully. They gave her some fluids for supportive cares, gave her some pain meds, particularly with Tylenol and then held off on the NSAIDs given that risk of bleeding with her lower platelet count. They did do an abdominal workup as well, which was all reassuring. And then they discharged her with close ID follow-up. So everything looks really good.

Dr. Bryan Fate: I was actually surprised, I didn’t know dengue was that prevalent in Mexico.

Dr. Sydney Notermann: I know, I didn’t either.

Dr. Bryan Fate: So thank you, Yellow Book.

Dr. Sydney Notermann: Mm-hmm.

Dr. Bryan Fate: There’s a theme of this episode is that the Yellow Book is helpful for really narrowing what can be a really wide and overlapping differential. A lot of things give you fever and rash it turns out, and teasing those things apart can be a tough job. So thank you for that resource. And I think we have just a few take home points today. Number one, fever in a returning traveler is typically attributable to common infectious processes also found at home so don’t forget those. However, especially if unusual symptoms, prolonged fever or ill appearance, a careful travel history should be undertaken, including exact locations, activities, vaccine status, and exposures. I’m also going to put a plug in that not everyone coming back from another country that has a fever needs all of this workup, it is specific to kind of, again, unusual presentation, prolonged fever, ill appearance. So you can certainly do first line strep, COVID, flu, your typical workup.

Number two, when evaluating fever in a returning traveler, the Yellow Book is an excellent point of care resource to tailor your differential to specific infectious disease incidents by location.

And number three, malaria is the most common, potentially severe diagnosis for returning travelers. So don’t miss malaria. And if there is suspicion for dengue fever, clinicians should be aware of the uncommon but potentially fatal critical phase of dengue typically occurring after defervescence. So it’s kind of biphasic, almost like viral to bacterial [inaudible 00:20:21], I like to think, that presents with thrombocytopenia, hemorrhage, shock, multisystem, organ involvement. You are very, very sick and all we can do is supportive care, unfortunately. So I’m glad that our 17-year-old got better, hopefully will be protected from mosquitoes next time that she goes back to Mexico, and I will too. Hopefully we have sufficiently motivated everyone to go to a travel clinic before their next international adventure.

Dr. Kade Goepferd: Thank you for listening to Talking Pediatrics. Come back next time for a new episode with our caregivers and experts in pediatric health. Our showrunner is Cora Nelson. Episodes are produced, engineered and edited by Jake Beaver and Patrick Bixler. Our marketing representatives are Amie Juba and Krithika Devanathan. For information and additional episodes, check us out on your favorite podcast platform or go to childrensmn.org/talkingpediatrics.