What is the workup for a patient with fever and rash all over the body with a travel history?

Workup for Fever and Rash in a Returning Traveler

The workup for a patient with fever and rash all over the body with travel history should prioritize ruling out potentially life-threatening tropical infections, particularly malaria, dengue fever, rickettsial infections, and viral hemorrhagic fevers. 1

Initial Assessment

• Travel history details: Obtain specific information about countries visited, exact dates of travel, activities undertaken (safaris, hiking, swimming), accommodations (urban vs. rural), and any known exposures to insects, animals, or ill individuals 1
• Timeline of symptoms: Determine onset of fever in relation to travel (during or after return) and progression of rash 1
• Rash characteristics: Document distribution pattern, morphology (maculopapular, petechial, etc.), timing of appearance in relation to fever 2
• Associated symptoms: Note presence of headache, myalgia, arthralgia, gastrointestinal symptoms, respiratory symptoms, or neurological manifestations 1

Essential Initial Investigations

• Malaria testing: Three thick and thin blood films over 72 hours and/or rapid diagnostic test (RDT) for any patient who has visited a tropical country within the past year 1
• Complete blood count: Look for thrombocytopenia (dengue, malaria), lymphopenia (viral infections, typhoid), or eosinophilia (parasitic infections) 1
• Blood cultures: At least two sets before initiating antibiotics (essential for diagnosing enteric fever) 1
• Liver function tests and renal function: To assess for organ involvement 1
• Urinalysis: Check for proteinuria/hematuria (leptospirosis) or hemoglobinuria (malaria) 1
• Chest X-ray: If respiratory symptoms are present 1

Specific Testing Based on Travel History and Clinical Presentation

Fever with Rash

• Dengue testing: PCR (positive 1-8 days post-symptom onset) or NS1 antigen test; IgM serology if >5 days since symptom onset 1, 3
• HIV testing: Consider acute seroconversion illness, especially with maculopapular rash 1
• Rickettsial testing: Acute phase serum (and convalescent serum 3-6 weeks later); consider empiric doxycycline if exposure to ticks, especially in game parks 1
• Chikungunya testing: PCR (1-4 days) or IgM (>5 days) if travel to endemic areas 1
• Viral hemorrhagic fever (VHF) assessment: If travel to endemic areas, contact regional infectious disease center for guidance on appropriate testing 1

If Jaundice Present

• Leptospirosis testing: CSF and blood cultures; consider empiric doxycycline or penicillin 1
• Viral hepatitis markers: Anti-HAV IgM, HBsAg, anti-HEV IgM 1
• Yellow fever testing: EDTA blood sample for PCR and serology if appropriate travel history 1

If Hepatosplenomegaly Present

• Abdominal ultrasound: To assess for liver abscess or other pathology 1
• Amoebic serology: If liver abscess suspected 1
• Brucella testing: Extended blood cultures and serology if contact with livestock or unpasteurized dairy products 1
• Visceral leishmaniasis testing: Serology and possibly bone marrow examination if travel to endemic areas 1

Empiric Treatment Considerations

• Malaria: Treat empirically if high suspicion and patient appears ill, even with initial negative tests 1
• Rickettsial infections: Consider empiric doxycycline if exposure to ticks in game parks with fever, headache, and rash/eschar 1
• Enteric fever: If clinically unstable with appropriate travel history, consider empiric ceftriaxone while awaiting culture results 1
• Dengue: Supportive care with close monitoring of platelet count and hematocrit; avoid aspirin due to bleeding risk 1, 2

Special Considerations

• Isolation precautions: Implement appropriate isolation for suspected cases of viral hemorrhagic fevers, measles, enteric fever, or other contagious diseases 1
• Laboratory notification: Alert laboratory staff when suspecting infections that pose occupational hazards (brucellosis, viral hemorrhagic fevers, Q fever) 1
• Public health notification: Report notifiable diseases to local health protection units 1

Common Pitfalls to Avoid

• Focusing only on tropical diseases: Common cosmopolitan infections may present during or after travel 4
• Missing malaria: Failure to perform repeated malaria testing can lead to missed diagnoses 1
• Delayed diagnosis of dengue: The characteristic rash may appear after initial fever subsides; look for "isles of white in a sea of red" 5
• Overlooking rickettsial diseases: These may present with subtle rash and are easily treatable but potentially fatal if missed 1
• Failing to consider non-infectious causes: Drug reactions and autoimmune conditions can mimic infectious exanthems 6