What is the appropriate management for a patient presenting with fever, body aches, chills, fatigue, cough, loss of appetite, dystonia, unsteady gait, hyperglycemia, and anemia after returning from travel to Lebanon, with negative COVID-19 and influenza tests?

Management of Febrile Illness in a Returned Traveler from Lebanon

This patient requires immediate malaria testing (thick blood film and rapid diagnostic test) and empirical antibiotic therapy for suspected enteric fever while awaiting culture results, given the concerning neurological symptoms (dystonia, unsteady gait) and recent travel from the Middle East. 1, 2

Immediate Diagnostic Workup

Malaria must be excluded first, even though Lebanon is not typically considered high-risk for malaria transmission. The American College of Physicians mandates malaria testing in all patients with fever who have visited any tropical or subtropical country within the past year, as this is the most important potentially fatal cause of tropical fever. 2

• Perform both thick blood film and rapid diagnostic test (RDT) simultaneously for initial malaria workup 2
• If initial tests are negative but clinical suspicion remains, repeat testing: three thick films/RDTs over 72 hours are required to confidently exclude malaria 2, 3

Obtain two sets of blood cultures immediately before starting antibiotics, as enteric fever (typhoid/paratyphoid) is a serious consideration from the Middle East/North Africa region. 1, 2

Additional mandatory initial investigations include: 2

• Complete blood count with differential (already done: Hgb 10.2 indicates anemia)
• Renal function and liver function tests
• Urinalysis
• Chest X-ray (given cough)
• Consider serum save for serology and EDTA sample for PCR

Critical Clinical Considerations

The neurological symptoms (dystonia and unsteady gait) are particularly concerning and warrant urgent attention. These could represent:

• Cerebral complications of enteric fever
• Hypoglycemia (BS 236 makes this less likely but monitor closely)
• Rickettsial infection
• Viral encephalitis
• Brucellosis (given Middle East travel and potential livestock exposure) 1

Document detailed travel history on all laboratory request forms: 2

• Exact locations visited within Lebanon
• Dates of travel and symptom onset (3 days post-return)
• Risk activities undertaken (unpasteurized dairy, livestock contact, tick exposure)
• Immunization history and malaria prophylaxis use

Empirical Treatment Decision

Start empirical antibiotics immediately without waiting for culture results given the neurological symptoms and systemic illness. 2, 3

For suspected enteric fever from the Middle East/North Africa region: 1

• Ceftriaxone is the first-line empirical choice if the patient appears clinically unstable
• If clinically stable and traveled from Middle East/North Africa, ciprofloxacin remains an alternative (resistance rates are lower than in South/Southeast Asia) 1
• Treatment duration: 2 weeks 1
• If confirmed sensitive, switch to ciprofloxacin; if resistant, use azithromycin as oral follow-on agent 1

Do not delay empirical treatment while pursuing diagnosis in severely ill patients. 2, 3

Additional Diagnostic Considerations for Middle East Travel

Brucellosis should be strongly considered given Middle East travel: 1

• Obtain extended blood cultures and serology
• Suspect if contact with livestock or consumption of unpasteurized milk
• Discuss treatment with infectious disease specialist if confirmed 1

Rickettsial infections should be on the differential, especially if there was outdoor/rural exposure: 1

• Obtain acute phase serum (save for 3-6 week convalescent serum)
• Consider empirical doxycycline if high suspicion

Leptospirosis if there was freshwater exposure: 1

• Blood cultures if <5 days from symptom onset
• Consider empirical doxycycline or penicillin 1

Management of Concurrent Issues

Address the hyperglycemia (BS 236):

• Monitor glucose closely, as hypoglycemia can occur with severe infections, particularly malaria 1
• Enteric fever patients may develop metabolic derangements

Address the anemia (Hgb 10.2):

• This could represent hemolysis from infection, chronic disease, or nutritional deficiency
• Monitor hemoglobin trends
• Consider hemolysis workup if malaria is confirmed

Consultation and Disposition

Immediate consultation with infectious disease/tropical medicine specialists is indicated for: 2

• Undiagnosed fever with neurological symptoms after initial workup
• Positive malaria films requiring confirmation and species-specific treatment
• Critically ill patients with tropical exposure

Hospitalization is warranted given: 3

• Evidence of neurological dysfunction (dystonia, unsteady gait)
• Systemic symptoms requiring close monitoring
• Need for parenteral antibiotics
• Anemia requiring investigation

Common Pitfalls to Avoid

• Do not assume Lebanon is "low-risk" for tropical diseases - the Middle East/North Africa region has specific endemic infections including enteric fever, brucellosis, and rickettsial diseases 1
• Do not wait for negative malaria tests to start antibiotics - perform testing simultaneously but start empirical treatment if clinically indicated 2, 3
• Do not attribute neurological symptoms to hyperglycemia alone - investigate for infectious causes of CNS involvement 1
• Do not discharge without excluding life-threatening causes - fever in returned travelers can be rapidly progressive and lethal 1, 4