Diagnosis and Management of International Travel-Related Illnesses in Urgent Care Patients (Infectious Disease CME and Pharmacology CME)

Table of Contents

 

About This Issue

Urgent care clinics have an important role to play as a first-line facility for patients who return from international travel with illness. This issue of Evidence-Based Urgent Care explores the complexities of diagnosing and managing travel-related presenting complaints such as fever, rash, and diarrhea in the urgent care setting. The importance of obtaining a detailed travel history for accurate diagnosis and initiating treatment is crucial to effective management of infectious diseases. Critical “do not miss” diseases are also reviewed. In this issue, you will learn:

The etiology and pathophysiology of common clinical conditions encountered in patients who have traveled;

How a travel history and thorough physical examination can help diagnose and manage nonendemic diseases that present with a chief complaint; and

The most effective treatments for common travel-acquired conditions and whether referral or transfer to the emergency department is needed.

CODING & CHARTING: Coding for encounters with patients who have infectious nonendemic diseases can be complex. Learn more in our monthly coding column.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Etiology and Pathophysiology
6. Differential Diagnosis
7. Urgent Care Evaluation
   1. History
   2. Physical Examination
8. Diagnostic Studies
9. Symptom-Based Evaluation and Management
   1. Fever
      1. Malaria
      2. Arbovirus
   2. Gastrointestinal Distress
      1. Travelers' Diarrhea
      2. Cholera
      3. Cryptosporidium
      4. Giardia
      5. Dysentery
      6. Parasitic Worms
   3. Hepatobiliary Symptoms
   4. Dermatologic Findings
   5. Respiratory Symptoms
   6. Psychiatric Issues
10. Special Populations
11. Controversies and Cutting Edge
12. Summary
13. 5 Things That Will Change Your Practice
14. Time- and Cost-Effective Strategies
15. KidBits: The Pediatric Traveler
    1. Travel Screening
    2. Dermatological Conditions
    3. Gastrointestinal Distress
    4. Febrile Illness
    5. Respiratory Symptoms
    6. Summary
    7. References
16. Critical Appraisal of the Literature
17. Case Conclusions
18. Risk Management Pitfalls for the Diagnosis and Management of International Travel-Related Illnesses in Urgent Care Patients
19. Coding & Charting: What You Need to Know
    1. Determining the Level of Service
    2. Problems Addressed
    3. Complexity of Data
    4. Risk of Patient Management
    5. Documentation Tips
20. Coding Challenge
21. Clinical Pathway for Diagnosis and Management of International Travel-Related Febrile Illnesses in Urgent Care Patients
22. References

Abstract

A significant number of people who travel internationally each year will develop a travel-related illness while traveling or shortly after returning. Many illnesses acquired abroad can be identified and treatment initiated in the urgent care setting. This review provides evidence-based guidance for the diagnosis and treatment of the most common presenting symptoms in returning travelers, including fever, diarrhea, and rash. Geographic distributions, incubation periods of pathogens, and comparisons of the clinical and laboratory features of different etiologies are provided to aid in diagnosis, with an emphasis on critical diseases that must not be missed. Specific pharmacological interventions and other treatment strategies are also discussed.

Case Presentations

A 32-year-old man who recently returned from a 1-week trip to Thailand presents to urgent care with a fever of 104.5˚F…

• He also reports headaches, malaise, and nausea for the past 2 days.
• He does not appear toxic and there is no rash.
• The purpose of his trip was primarily business, but he says that he did some “touristy things” while he was in Thailand.
• You wonder if this is a viral syndrome that needs only supportive care. Could the travel to Thailand be significant?

A 60-year-old woman with well-controlled hypertension presents to urgent care with a fever of 104˚F…

• She also reports arthralgias, myalgias, and a retrobulbar headache.
• She returned from a Caribbean cruise 1 day ago, and notes that her symptoms began on the last day of the trip.
• She says that she tried to be careful about what she ate and only drank bottled water. She enjoyed the outdoor cafes during port-of-calls, but notes that “the mosquitoes were horrible.”
• You wonder what “souvenir” she may have picked up…

A 20-year-old man presents to urgent care with a diffuse, pruritic rash of 10 days’ duration…

• He returned a week ago from a month-long trip to Indonesia.
• The trip was very low-budget, and he stayed primarily in youth hostels or “rustic” local inns in rural areas.
• He reports that he ate “whatever looked good at the time.“
• You wonder what may be “eating“ him…

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Clinical Pathway for Diagnosis and Management of International Travel-Related Febrile Illnesses in Urgent Care Patients

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

4. * Itzkowitz E, Alpert EA, Farojeh AZ, et al. Morbidity of returning travelers seen in community urgent care centers throughout Israel. Trop Med Infect Dis. 2023;8(6). (Prospective observational study; 1580 patients) DOI: 10.3390/tropicalmed8060319

9. * Camprubí-Ferrer D, Cobuccio L, Van Den Broucke S, et al. Causes of fever in returning travelers: a European multicenter prospective cohort study. J Travel Med. 2022;29(2):taac002. (Prospective multicenter cohort study; 765 patients) DOI: 10.1093/jtm/taac002

15. * Heather CS. Travellers’ diarrhoea. BMJ Clin Evid. 2015;2015:0901. (Systematic review; 24 studies) PMID: 25928418

20. * Thakker C, Warrell C, Barrett J, et al. UK guidelines for the investigation and management of eosinophilia in returning travellers and migrants. J Infect. 2025;90(2):106328. (Clinical practice guidelines) DOI: 10.1016/j.jinf.2024.106328

25. * Efstathiadou A, Tsourouktsoglou H, Shipman AR. Skin dermatoses in the returning traveller: a practical guide. Clin Exp Dermatol. 2024;49(11):1289-1300. (Review) DOI: 10.1093/ced/llae114

27. * Beny A, Paz A, Potasman I. Psychiatric problems in returning travelers: features and associations. J Travel Med. 2001;8(5):243-246. (Retrospective cohort study; 15 patients) DOI: 10.2310/7060.2001.24019

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Keywords: travel, travel-related disease, travel history, returning traveler, international traveler, geographic distribution, “exotic disease”, incubation, infectious agents, chemoprophylaxis, malaria, arbovirus, dengue, chikungunya, Zika, invasive protozoa, parasitic worms, helminths, hepatitis, cholera, dysentery, liver disease, visceral leishmaniasis, contact dermatitis, rash, fever, diarrhea, travelers’ diarrhea, fungal infection, acute respiratory infection, tuberculosis, pulmonary fungal disease, parasitic lung disease, COVID-19, pneumonia, influenza, Shigella, Vibrio, Salmonella, E coli, blood smear, febrile illness, Plasmodium falciparum, P ovale, P vivax, P malariae, P knowlesi, Cryptosporidium, Giardia, trichuriasis, ascariasis, biliary fluke infections, invasive amoebiasis, jetlag, psychosis, delusional parasitosis, schizophrenia, leprosy, rickettsioses, schistosomiasis, histoplasmosis, coccidioidomycosis, tuberculosis, Middle East Respiratory syndrome, enteric fever, viral hemorrhagic fever, strongyloidiasis, artemisinin-based combination therapy, Taenia, Ascaris, hookworm, bedbugs, ticks, mosquitoes, mites, myiasis, fleas, visceral larva migrans, chloroquine