Recognition and Management of Pediatric Travel-Associated Infectious Diseases in the Emergency Department (Infectious Disease CME and Pharmacology CME) -

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Publication Date: November 2021 (Volume 18, Number 11)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. CME expires 11/01/2024.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Infectious Disease CME and 1.5  Pharmacology CME credits, subject to your state and institutional approval.

Authors

Peer Reviewers

Abstract

Global travel has made travel-associated infectious diseases (TAIDs) a more frequent consideration in the pediatric emergency department. Studies show that physicians may either omit a travel history or, even with a positive travel history, do not consider potentially serious illnesses, such as dengue and malaria. A thorough travel history including the purpose, location, activities, diet, and exposures can help the emergency clinician develop and narrow the differential diagnosis. This issue reviews the epidemiology, clinical presentation, diagnosis, and management of various TAIDs, with the goal of early recognition and disease-specific treatment.

Case Presentations

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?

A fully vaccinated 2-year-old girl presents to the ED with 3 days of fever and diarrhea...

• The fever and diarrhea started 8 days after returning from a trip with her parents to visit friends and relatives in Pakistan. The family did not receive pretravel consultation and no vaccines or prescriptions were received before the trip. The relatives live in a rural village that is reached by a 3-hour bus ride from Lahore. The family ate food prepared by local families and drank from local water supplies. The child played outside with other children and the family’s dogs. The patient’s 5-year-old sibling also had diarrhea, but this resolved after 2 days. The parents report that none of the relatives in Pakistan are ill. The family did not use insect repellent or bed nets during their stay, and the parents say they remember seeing insect bites on the child. The child was not sick during their travel and had no local medical care.
• The girl’s vital signs are: temperature, 39°C; heart rate, 88 beats/min; respiratory rate, 22 breaths/min; blood pressure, 100/60 mm Hg; oxygen saturation, 98%. The patient is quiet and looks somewhat listless. Her ears and throat look normal, and her lungs are clear. There is no hepatomegaly. There is a diffuse maculopapular rash that is more prominent on the torso.
• Based on the travel to Pakistan and possible exposure to contaminated water, you know there is a risk for enteric fever. What laboratory tests would help confirm the diagnosis? Does the treatment differ based on the location of travel? If the patient is able to tolerate liquids and can be managed as an outpatient, what signs or symptoms should prompt return to the ED?