Approach to fever in the returning traveler

Fever in the returning traveler is a common clinical scenario that often leads to hospitalization and may be the only symptom of a serious or life-threatening illness.1 Three percent of 784 Americans who traveled abroad for short periods reported an episode of febrile illness,2 and fever was the chief symptom in 28% of 24,920 ill travelers who presented to travel clinics on their return home.3 The absolute number of travelers is large and rising, with the International Tourism Organization reporting 1.2 billion trips in 2015, an increase of 4.4% from the previous year.4 The challenge presented by returning travelers with febrile illnesses is changing for two reasons. First, increasing numbers of travelers are older than 60 years of age or are seeking health care elsewhere ("medical tourists"), and these travelers are more likely than others to have clinically significant coexisting conditions and consequently increased morbidity from infections. Second, the likelihood of multidrug resistance in the infecting organisms is increasing. The recent Ebola epidemic in West Africa, the emergence of the Middle East respiratory syndrome coronavirus (MERS-CoV), and the reemergence of Zika and chikungunya viruses have highlighted the importance of being alert to the possibility that an emerging pathogen is causing a febrile episode. Fever in the returning traveler is an evolving clinical challenge, with respect to both the infections responsible for the fever and the sources and quality of information available to assist the physician. We review available sources of global information on outbreaks and the epidemiologic features of infectious diseases and offer a practical approach to emerging or transmissible infectious diseases that may pose a life-threatening risk to patients, as well as clinicians and laboratory workers.