Fever in a patient from the tropics


Fever is a common presentation in people who have recently arrived in Britain from tropical countries. The most common diagnoses are listed in table. The most important is malaria, because untreated Plasmodium

Causes of fever imported into the UK
Frequency Cause
Common Malaria Presumed viral
Frequent Bacterial dysentery, upper respiratory tract including diphtheria, pneumonia, urinary tract. typhoid Proven viral hepatitis A, HIV, Epstein-Barr virus, aseptic meningitis, dengue
Occasional Tuberculosis, toxoplasmosis, rickettsial
Rare Brucellosis, amoebic abscess, visceral leishmaniasis
On admission
  • Thick and thin blood films for malaria, repeat if negative
  • Full blood count (neutrophilia, eosinophilia, thrombocytopenia, atypical lymphocytes)
  • Cultures of blood x 3 (or bone marrow x 1 if the patient has had an antibiotic), urine, throat swab and stool if diarrhoea
  • Liver function tests
  • Dip-stick urine for blood, protein, bile
  • Store serum for possible serology later
  • Consider lumbar puncture for neck stiffness
  • Treat clinically diagnosed infection for which there is no rapid confirmatory test (e.g. tick-typhus) or where delay is unjustified (e.g. malaria)
Over the next 3 days
  • Re-examine the patient and look for new signs
  • Treat infection diagnosed
  • Consider Lassa fever if from endemic area
After 3 days
  • Reassess. If getting better, wait. If not:
  • Repeat initial tests
  • Consider chest radiograph, abdominal ultrasound scan
  • Consider serology for Epstein-Barr virus, HIV, dengue, Rickettsia, Toxoplasma, Entamoeba, Schistosoma, according to clinical and epidemiological situation
  • Consider treatment on clinical grounds alone (e.g. getting worse and clinical features suggest typhoid)
After 10 days
  • Consider more chronic infections (e.g. tuberculosis, brucellosis, HIV, leishmaniasis)
  • Consider non-infectious diseases
  • Obtain a second opinion

falciparum infection in a non-immune patient (including expatriates and immigrants of over 3 years' duration) may become rapidly fatal. P. falciparum malaria usually presents within 2 months of arrival but occasionally up to 6 months later, rarely longer. The clinical features of malaria they may include fever, cough and diarrhoea. The pattern of fever does not distinguish malaria from other imported or domestic fevers such as influenza, but splenomegaly, thrombocytopenia and hyperbilirubinaemia strongly suggest the diagnosis Asian immigrants are at especial risk of tuberculosis and Africans of HIV infection Physical examination should be directed especially towards:

  • the skin (rashes in meningococcaemia, dengue, nickettsioses, typhoid)
  • the chest (bronchitis and pneumonitis are features of malaria and typhoid)
  • the lymph glands (toxoplasmosis and seroconversion illness of infectious mononucleosis and HIV infection)
  • the spleen (malaria, typhoid, acute schistosomiasis, leishmaniasis)
  • the liver (hepatitis, amoebic abscess)
  • neck stiffness (meningitis).

The investigation and management of fever from the tropics are shown in the information box.

Concepts of infection
Major manifestations of infection
Principles of management of infection
Diseases due to viruses
DNA viruses
Diseases due to chlamydiae
Diseases due to rickettsiae
Diseases due to bacteria
  • Streptococcal infections
  • Staphylococcal infections
  • Corynebacterial infections
  • Bacillus infections
  • Bordetella infections
  • Salmonella infections
  • Food poisoning
  • Dysentery
  • Other true bacterial infections
  • Mycobacterial infections
Diseases due to spirochaetes
  • Leptospira infections
  • Borrelia infections
  • Treponema infections
Diseases due to fungi (mycoses)
  • Cutaneous fungal infections
  • Subcutaneous fungal infections
  • Systemic fungal infections
Diseases due to protozoa
Diseases due to helminths
  • Trematode (fluke) infections
  • Cestode (tapeworm) infections
  • Nematode (roundworm) infections
  • Zoonotic helminth infections
Diseases due to arthropods
Sexually transmitted diseases
  • Sexually transmitted bacterial diseases
  • Sexually transmitted viral diseases
  • Miscellaneous conditions