Chapter 67

• Nonspecific viral illness is the most common final diagnosis in pediatric patients admitted to the hospital with febrile illnesses after traveling.
• Blood cultures and thin and thick smears for malaria are important initial tests for all travelers returning from an area endemic for malaria. If the first smears are negative and the diagnosis is not established, repeat smears should be obtained every 8 to 24 hours until it is certain that malaria is not the cause of the fever.
• Anemia is common in many diseases but hemoconcentration, especially in combination with thrombocytopenia, may indicate dengue fever.
• Eosinophilia is defined as a peripheral eosinophil count of > 400 to 500 cells/mm3. In the returning traveler, especially if fever is noted, helminth infection is suggested.
• Malaria most commonly presents as a nonspecific influenza-like syndrome with high fever, chills, rigors, sweats, and headache and is frequently misdiagnosed as a viral syndrome. These symptoms are unreliable in clinical practice and no combination of fever pattern, duration of symptoms, or physical findings can reliably rule out malaria.
• The laboratory diagnosis of malaria has not changed markedly over the past century. The use of thick and thin peripheral blood smears using Giemsa stain remains the “accepted diagnostic technique for malaria.”
• The most practical approach in the emergency department is to assume that all malaria is chloroquine resistant.
• Falciparum malaria can progress rapidly to become a medical emergency. If falciparum malaria is diagnosed or reasonably suspected, the patient should be admitted to the hospital and treatment started.
• In a critically ill child with malaria, falciparum should be presumed until proven otherwise and parenteral treatment with quinine or quinidine should be started. These medications require cardiac monitoring with particular attention to the QT interval and to hypotension.
• If neither quinidine nor quinine is available, clindamycin can be used as a temporizing medication.
• Classic dengue fever is an acute onset febrile illness with a variety of nonspecific symptoms. In addition to fever, the most commonly reported symptoms in older children and adolescents include rash, headache, retro-orbital pain, myalgias, and arthralgias. The arthralgias and myalgias can be so severe that dengue fever has been given the nickname “breakbone fever.”
• The etiology of traveler's diarrhea (TD) has been somewhat elusive as medical workups infrequently yield a bacteria, virus, or parasite. However, the fact that prophylactic antimicrobial agents markedly reduce the attack rate suggests that an infectious bacterial process is often responsible.
• The most important intervention for diarrhea is replacement of fluid and electrolyte losses.
• There is theoretical concern that antimotility agents may prolong the course of disease caused by invasive enteropathogens. Use in children remains controversial because of concerns that it might aggravate disease caused by invasive enteric pathogens.
• Typhoid fever (TF) continues to be a global health problem, but in the developed world it is now thought of primarily as a travel-related disease.

Emergency department physicians face the challenging task of evaluating patients who have returned with illnesses acquired while abroad. Nearly two ...

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