EBMedicine

What’s Your Diagnosis? Pediatric Travel-Associated Infectious Diseases in the ED

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got last Management of Pediatric Transplant Patients in the Emergency Department right.

Case Presentation: Recognition and Management of Pediatric Travel-Associated Infectious Diseases in the Emergency Department

A 12-year-old boy with no past medical history presents to your ED with fever for 4 days to 40°C with associated headache and abdominal pain… 

The boy has been eating and drinking less and is less active. His vital signs are: temperature, 39.8°C; heart rate, 175 beats/min; respiratory rate, 32 breaths/min; blood pressure, 92/68 mm Hg, and oxygen saturation, 96%. He appears pale and quiet but does not seem toxic. His ears and throat look normal. His lungs are clear. His heart is tachycardic without murmur. His abdomen is soft and nontender, without organomegaly. There is no rash. His capillary refill is normal. A diligent resident discovers that the family returned recently from the Philippines. 

You wonder: is this is a viral syndrome that needs only supportive care? Could the travel to the Philippines be significant? What diseases are endemic to the Philippines? What other details about the travel might be helpful? Do you need to send laboratory tests? Do you need to start empiric treatment? 

Case Conclusion

A detailed travel history revealed that the family returned 1 week ago from a 2-week tourist trip to Palawan, during which they participated in many outdoor and water-based activities. The family denied a pretravel visit with their pediatrician and denied using prophylactic medications for malaria. The patient was previously vaccinated for yellow fever and hepatitis A. He received a typhoid vaccine 1 year ago before international travel. The family reported that they drank only bottled water, but they did eat food from street vendors. They stayed only in hotels. They said no one else in the family was sick. There was no local medical care. Using the CDC travel website, the resident searched for TAIDs that are present in the Philippines and found that the patient was at risk for malaria, dengue, typhoid fever, rickettsial disease, chikungunya, Zika, and leptospirosis. A malaria blood smear was negative. Testing was sent for the other TAIDs listed. Blood and urine cultures were sent. CBC, LFTs, and electrolytes testing showed no significant abnormalities. After receiving acetaminophen in the ED, the boy’s temperature normalized and his headache resolved. He was able to tolerate fluids. The patient was discharged on oral doxycycline, pending the results of cultures and disease-specific testing. The pediatrician was contacted and said she will repeat the malaria blood smears and follow the results of the pending laboratory studies. The patient improved after 2 days of antibiotics. The Department of Health contacted the pediatrician with a positive PCR for leptospirosis. 

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