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

Table of Contents

 

About This Issue

As many as 75% of cases of travel-associated infectious diseases (TAIDs) are missed initially, and this occurs more often in children than in adults. A thorough travel history can help the emergency clinician develop and narrow the differential diagnosis. This issue reviews the components of a thorough travel history, identifies risk factors for various TAIDs, and reviews the distribution, diagnosis, and management of various TAIDs that can present in pediatric return travelers. You will learn:

Key aspects of a complete travel history, including the reason for travel, location, itinerary, activities, diet, and exposures

Risk factors for various TAIDs

Signs and symptoms associated with TAIDs presenting with fever

Common causes of traveler’s diarrhea, as well as options for treatment

Skin findings associated with cutaneous larva migrans, myiasis, tungiasis, and leishmaniasis

Disease-specific information for diagnosis and management of malaria, dengue, enteric fever, chikungunya, Zika virus infection, rickettsioses, schistosomiasis, viral hemorrhagic fevers, and leptospirosis

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. Travel History
      1. Purpose of Travel
      2. Travel Itinerary
      3. Timing of Symptom Onset
      4. Dietary History
      5. Exposures/Activities
      6. Bites
      7. Prevention: Pretravel Immunizations and Prophylaxis
      8. Sick Contacts
      9. Infection or Similar Symptoms in Co-Travelers
      10. Medical Care Abroad
   2. Physical Examination
      1. Fever
      2. Diarrhea
      3. Respiratory
      4. Skin Findings
      5. Neurologic
9. Diagnostic Studies
10. Management of Specific Travel-Associated Infectious Diseases
    1. Malaria
    2. Dengue
    3. Enteric Fever
    4. Chikungunya
    5. Zika
    6. Rickettsioses
    7. Schistosomiasis
    8. Viral Hemorrhagic Fevers
    9. Leptospirosis
11. Special Populations
12. Controversies and Cutting Edge
    1. Tests for Malaria
    2. Tests for Enteric Fever
    3. Tests and Treatment for Schistosomiasis
13. Disposition
14. Summary
15. Time- and Cost-Effective Strategies
16. Risk Management Pitfalls for Pediatric Patients With Travel-Associated Infectious Diseases
17. Case Conclusions
18. Clinical Pathway for Management of Pediatric Patients With Suspected Malaria
19. Tables, Figures and Appendix
    1. Table 1. Associated Signs and Symptoms for TAIDs Presenting With Fever
    2. Table 2. Antimicrobial Therapy for Traveler’s Diarrhea
    3. Table 3. Dosing Information for Treatment of Malaria
    4. Table 4. Treatment Options for Enteric Fever
    5. Figure 1. Cutaneous Larva Migrans
    6. Figure 2. Myiasis and Larvae of Human Botfly Dermatobia hominis
    7. Figure 3. Tungiasis
    8. Figure 4. Various Presentations of Cutaneous Leishmaniasis in Children
    9. Figure 5. Neurocysticercosis Appearance on Computed Tomography Scan Without Contrast (Left) and With Intravenous Contrast (Right)
    10. Figure 6. Worldwide Distribution of Malaria Transmission
    11. Figure 7. Worldwide Distribution of Dengue
    12. Figure 8. Tourniquet Test for Dengue
    13. Figure 9. Worldwide Distribution of Enteric Fever
    14. Figure 10. Rose Spots of Enteric Fever
    15. Figure 11. Distribution of Rocky Mountain Spotted Fever
    16. Figure 12. Rash of Rocky Mountain Spotted Fever
    17. Figure 13. Worldwide Distribution of Schistosomiasis
    18. Appendix 1. Geographic Regions With Associated TAIDs
    19. Appendix 2. Incubation Periods of Common TAIDs That Present With Fever
    20. Appendix 3. Dietary Activities and Associated TAIDs
    21. Appendix 4. Patient Exposures/Activities and Associated TAIDs
    22. Appendix 5. Animal Exposures and Associated TAIDs
20. References

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?

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Clinical Pathway for Management of Pediatric Patients With Suspected Malaria

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Tables, Figures and Appendix

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Key References

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

17. * Crowell CS, Stamos JK. Evaluation of fever after international travel. Pediatr Ann. 2011;40(1):39-44. (Review) DOI: 10.3928/00904481-20101214-09

20. * Flores MS, Hickey PW, Fields JH, et al. A “syndromic” approach for diagnosing and managing travel-related infectious diseases in children. Curr Probl Pediatr Adolesc Health Care. 2015;45(8):231-243. (Review) DOI: 10.1016/j.cppeds.2015.06.005

28. * Fox TG, Manaloor JJ, Christenson JC. Travel-related infections in children. Pediatr Clin North Am. 2013;60(2):507-527. (Review) DOI: 10.1016/j.pcl.2012.12.004

29. * Centers for Disease Control and Prevention. CDC Yellow Book 2020: Health Information for International Travel. New York, NY: Oxford University Press; 2020. (Textbook) 

53. * Nield LS, Stauffer W, Kamat D. Evaluation and management of illness in a child after international travel. Pediatr Emerg Care. 2005;21(3):184-195. (Review) DOI: 10.1097/01.pec.0000161476.88453.04

57. Centers for Disease Control and Prevention. Treatment of malaria (guidelines for clinicians). Accessed October 15, 2021. (Online reference)

64. Centers for Disease Control and Prevention. Dengue. For healthcare providers. Clinical presentation. Accessed October 15, 2021. (Online reference)

67. Sharp TM. CDC Expert Commentary: differentiating chikungunya from dengue: a clinical challenge. Accessed October 15, 2021. (Online reference)

69. Centers for Disease Control and Prevention. Dengue. For health providers. Diagnosis. Accessed October, 15 2021. (Online reference)

90. Centers for Disease Control and Prevention. Chikungunya virus: clinical evaluation and disease. Accessed October, 15, 2021. (Online reference)

95. Centers for Disease Control and Prevention. Zika virus. For healthcare providers. Clinical evaluation & disease. Accessed October 15, 2021. (Online reference)

119. Centers for Disease Control and Prevention. Parasites - schistosomiasis; resources for health professionals. Accessed October 15, 2021. (Online reference)

130. U.S. Centers for Disease Control and Prevention. Antibiotic treatment. Recommendations for the use of antibiotics for the treatment of cholera. Accessed October 15, 2021. (CDC guideline)

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Keywords: travel-associated infections, travel-associated infectious diseases, TAID, travel history, traveler’s diarrhea, amebiasis, Middle East respiratory virus, MERS, cutaneous larva migrans, myiasis, tungiasis, leishmaniasis, cysticercosis, malaria, Plasmodium, uncomplicated malaria, severe malaria, malaria prophylaxis, malaria treatment, dengue, tourniquet test, dengue treatment, enteric fever, typhoid fever, paratyphoid fever, rose spots, enteric fever treatment, chikungunya, Zika, Zika virus, Zika virus infection, rickettsioses, Rocky Mountain spotted fever, Mediterranean spotted fever, African tick-bite fever, rickettsiosis treatment, schistosomiasis, blood trematodes, Katayama syndrome, schistosomiasis treatment, viral hemorrhagic fevers, Ebola, leptospirosis, leptospirosis treatment