What is the appropriate workup and treatment for a returning traveler from Indonesia presenting with fever?

Workup and Treatment for Fever in Returning Traveller from Indonesia

The first step in managing a returning traveller from Indonesia with fever is to rule out malaria with urgent blood films, followed by targeted investigations for dengue and enteric fever, which are the most common serious tropical diseases in travellers returning from Southeast Asia. 1

Initial Assessment

Urgent Investigations

• Three malaria blood films (thick and thin) taken at 12-24 hour intervals, regardless of symptoms 1
• Complete blood count with attention to:
  • Thrombocytopenia (<150,000/μL) - highly suggestive of malaria or dengue 1, 2
  • Leukopenia - may suggest viral infection like dengue
• Blood cultures (before antibiotics) - essential for diagnosing enteric fever 1
• Liver function tests - may show mild transaminitis in many tropical infections
• Dengue PCR (if within 1-8 days of symptom onset) or IgM (after 5 days) 1
• Chest X-ray if respiratory symptoms present 3

Clinical Features to Assess

• Fever pattern and associated symptoms
• Rash (may suggest dengue, chikungunya, or rickettsial disease)
• Gastrointestinal symptoms (may suggest enteric fever or amoebic liver abscess)
• Headache, myalgia, arthralgia (common in malaria, dengue)
• Jaundice (may suggest severe malaria, viral hepatitis, or leptospirosis)
• Neurological symptoms (may suggest cerebral malaria or other CNS infections)
• Splenomegaly (highly suggestive of malaria with positive likelihood ratio of 13.6) 2

Management Algorithm Based on Clinical Presentation

1. If Malaria Suspected or Cannot Be Ruled Out

• Begin empiric treatment for malaria immediately if patient appears severely ill or has risk factors (thrombocytopenia, splenomegaly) while awaiting blood film results 1
• For P. falciparum from Indonesia:
  • Oral mefloquine 1250 mg (5 tablets) as a single dose for uncomplicated malaria 4
  • Alternative: Atovaquone-proguanil if available
  • For severe malaria: IV artesunate (if available) or IV quinine with urgent specialist consultation

2. If Dengue Suspected (Fever + Thrombocytopenia + Travel to Indonesia)

• Supportive management with close monitoring of platelet count and hematocrit
• Daily follow-up with CBC if outpatient management chosen
• Avoid aspirin and NSAIDs due to bleeding risk
• Monitor for warning signs of severe dengue (rapid drop in platelets, rising hematocrit) 1

3. If Enteric Fever Suspected (Persistent Fever + Normal/Low WBC + Abdominal Symptoms)

• Empiric treatment with ceftriaxone if clinically unstable
• Switch to ciprofloxacin if isolate is sensitive, or azithromycin if resistant
• Treatment duration: 2 weeks 1

4. If Undifferentiated Non-Malaria Fever

• Consider empiric doxycycline 100 mg twice daily for possible rickettsial diseases, leptospirosis, or Q fever, especially if malaria and dengue tests are negative 5
• Approximately 30% of undifferentiated fevers in returning travelers respond to doxycycline 5

Other Important Considerations

Amoebic Liver Abscess

• Consider in patients with fever, right upper quadrant pain, and hepatomegaly
• Investigate with abdominal ultrasound and amoebic serology
• Treat empirically with metronidazole or tinidazole if abscess seen on ultrasound 1

Leptospirosis

• Consider in patients with fever, jaundice, and history of freshwater exposure
• Treat empirically with doxycycline or penicillin if suspected 1

Chikungunya

• Consider in patients with fever and severe joint pain
• Diagnose with PCR (1-4 days) or IgM (>5 days)
• Manage symptomatically 1

Isolation Precautions

• Implement appropriate isolation for suspected enteric fever, viral hemorrhagic fevers, or other infectious diseases according to local guidelines 1
• Notify public health authorities for reportable diseases (malaria, dengue, typhoid) 1

Common Pitfalls to Avoid

1. Failing to obtain adequate malaria blood films (need three negative films to rule out malaria)
2. Delaying empiric treatment in severely ill patients while awaiting test results
3. Overlooking non-malarial causes of fever in travelers from Southeast Asia
4. Not considering dengue as a common cause of fever in travelers from Indonesia
5. Administering NSAIDs to patients with possible dengue (increases bleeding risk)

Remember that malaria can present up to a year after return from an endemic area, and symptoms may be non-specific. A high index of suspicion must be maintained even if initial tests are negative 1.