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Upon Your Return

By Dr. Mark Wise

Fever || Diarrhea || Honey ... I Passed A Worm!

Just because you have made it home doesn't mean you are out of the woods! Especially if you are not feeling too well. The commonest problems in returning travelers include diarrhea, and variations thereof, fever and skin rashes. By far the most concerning symptom in any traveler is a fever.

There is no shortage of tropical illnesses that the traveler can pick up while abroad. Malaria, diarrhea that just won't quit and skin rashes are just a few of the problems encountered. Therefore, if you feel unwell in some way upon your return, or have been away for a long time and have been exposed to numerous infections, it is worth getting checked by your family doctor or a tropical disease specialist.

Remember...
Fever in a returning traveler is a medical emergency.

Fever in a returning traveler is malaria until proven otherwise. 

FEVER
Fever in a returning traveler is malaria until proven otherwise. Malaria may occur as soon as ten days after entering a malarious area, but sometimes not for several months after exposure. This time difference may depend upon the strain of malaria, as well as other factors including whether or not antimalarials have been taken. P. falciparum, the most serious strain, will usually cause symptoms within 60 days of being exposed. P. vivax, which is no pleasure to have but which will rarely prove fatal, may persist in the liver for many months before entering the bloodstream and causing symptoms.

Aside from fever, malaria may also present with symptoms such as headache, chills, sweats, feeling hot and cold, muscle aches and pains, and more. The fever may occur on alternate days as it does in the textbooks, but this is not always the case. Several other infections, such as dengue fever, typhoid fever, hepatitis and the flu may present with similar symptoms. Non "tropical" infections, such as mononucleosis, kidney infections and pneumonia may also be associated with fever.

If you have returned from a malarious area and develop a fever, do the following:

  • seek medical attention and request / demand that you have a blood smear for malaria
  • if the results are not immediately available, make sure that the doctor will follow up with you within 24 hours
  • if the test is negative for malaria parasites, and you continue to have fever, it should be repeated; the first smear will not always be positive
  • if you do have malaria, be certain that your doctor has experience in dealing with this infection, or gets it quickly from someone else

North Americans occasionally die from malaria, because of:

  • improper or inadequate malaria prophylaxis
  • delay in seeking medical attention
  • missed or delayed diagnosis on the part of the doctor
  • inadequate medical treatment

If you do not have malaria, other investigations such as testing for hepatitis antibodies, blood, stool and urine cultures, x-rays or ultrasound may be necessary.

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DIARRHEA 
Up to 40% of travelerís to the tropics get Montezumaís Revenge, Delhi Belly, or just plain old diarrhea. Most have a mild illness and get better within day or two. Others become quite ill, and vow never to return. And some remain unwell upon their return home. Gas, bloating, rumbling, cramps Ö it never seems to end.

The commonest causes of Travelers Diarrhea are bacterial infections, such as E. coli, salmonella, shigella and campylobacter. These last three can make you particularly sick, sometimes with dysentery (fever, blood and pus in the stools). They usually have a brief incubation period of 24 to 48 hours. Therefore if it strikes you on the plane home or as you walk through your front door, you probably goofed on the last day of your vacation.

Parasites are a much less common cause of diarrhea in travellers. As well, they do not usually strike quite as acutely. The commonest parasitic infections included giardiasis and amebiasis. Two slightly newer or emerging infections are cryptosporidium and cyclospora. Many travellers and non-travellers alike seem to acquire Entamoeba coli, Endolimax nana, Entamoeba hartmanni and Dientamoeba fragilis. These latter amoebas are usually non-pathogenic, that is, they don't cause much in the way of illness. It is not necessary to travel abroad to acquire most of the above infections. They are available right here at home!

The diagnosis of these infections can sometimes be suspected clinically. The poor guy with fever, lower abdominal cramps, and blood streaked diarrhea probably has shigella. And the one who has been passing gas that curls your nose for two months, might have giardia. But the definitive diagnosis rests with examination of the stools.

Parasites are seen by looking at a concentrated sample under a microscope (O& P). It may be necessary to examine more than one specimen. Bacterial infections are detected by growing the bacteria (C&S).

Treatment is based upon the causative agent, as well as the clinical state of the patient. Antibiotics, such as Cipro and Noroxin, may be used for the treatment of bacterial infections. Antiparasitics, such as metronidazole (Flagyl) are used to treat parasitic infections such as giardiasis and amebiasis. Patients who are asymptomatic at the time of diagnosis may not need treatment, but washing oneís hands remains a good idea!

What about those people who are not yet better, and in whom nothing can be found in the stools? Firstly, we might consider some other diagnosis, such as Lactose Intolerance (an inability to digest the lactose found in dairy products). This condition may follow almost any bowel infection. It is usually transient. A lactose free diet may help, as might products such as Lactaid or Lacteeze.

Inflammatory bowel disease (ulcerative colitis, Crohnís Disease) is occasionally found in a returning traveller. This diagnosis would require further investigations such as colonoscopy and bowel biopsy.

Antibibiotic-induced colitis, caused by a bacteria, Clostridium difficile, occurs sometimes in travellers who have recently taken antibiotics. A special stool culture is needed for diagnosis.

Perhaps the most common diagnosis we are left with after a full investigation is a Post Infectious Irritible Bowel Syndrome. This means "I went to Vietnam, I got sick, I got better Ö. But Iím still not back to the way I was before." One might suffer with gas, bloating, rumbling and abdominal discomfort. Your stools may be loose, ribbony, pellet-like, or all of the above. You may be sensitive to certain foods that didnít bother you before. You shouldnít be losing weight or noticing any blood in your stools. This condition usually improves with time, fibre, a careful diet and a positive attitude!

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HONEY ... I PASSED A WORM!
Not everyone who returns from the tropics has the pleasure of passing a worm, but some do! It can be a little bit disconcerting to say the least, but donít let panic set in Ö. Grab that worm!

While there are a zillion different worms which infect humans, only four of them will make their exit via the rectum. Therefore it is fairly easy for someone with a bit of helminthic (worm) experience to figure out what species you have passed. After reading this section, you will also be able to make an educated guess. The four worms which I will describe differ in size, shape, length and means of acquisition.

Roundworms (Ascaris lumbricoides) are transmitted through infected food or water, and isusually acquired in the tropics, though there are some communities in North America where it is still transmitted. It is unlikely that the average traveller would encounter this charming worm, though those who are a bit off the beaten path might. The worm is usually a pinkish-white in colour, and is round, much like an earthworm. It can be up to 6 inches in length. Most infected people have no symptoms from a roundworm infection other than the sheer horror of seeing it crawl into the toilet bowl! Often, it is because they are unable to find a sexual partner that the lonely roundworm makes this terminal migration out of our bowels.

The whipworm (Trichuris trichiura) is also round, much shorter (about 1-2 inches), and curved somewhat like a bull whip. It is also limited to the tropics, where it is acquired through the ingestion of contaminated food and water. Considering that these worms do not divide in their human host, and that most people donít pick up very many worms to start with, they are usually fairly inocuous.

Pinworms (Enterobius vermicularis) are not at all tropical, but thrive in temperate climates, and they are the only one of our helminthic infections that can be immediately passed from person to person. The pinworm is the smallest of our four worms, measuring only ½ inch. They are also round and white. Adult pinworms inhabit the large intestine, and at nighttime, the fertilized female ventures towards the rectum to deposit her eggs. Why she does this at night is a Nobel Prize waiting to be won! These eggs are quite sticky, and irritating, so that most children, and adults, will eventually scratch the area, and more than likely then put their fingers in their mouth, or onto someone elseís hands. In this way, the infection can be easily passed on to others, or perpetuated within oneself. The usual symptoms are itching around the rectal area, at night, though sleeplessness, abdominal pains or vaginal symptoms may also occur. The tiny worms may be seen at night, especially if you shine your flashlight on the itchy area at midnight!

Tapeworms are a bit different. They are flat Ö. Almost ribbony. They are often passed as short little segments of less than an inch, but if the whole worm were passed intact, it could be as long as 30 feet! There are three human tapeworms, the beef tapeworm (taenia saginata), the pork tapeworm (taenia solium) and the fish tapeworm (diphyllobothrium latum). They are contracted by eating raw or undercooked meats. This is sometimes the local custom, sometimes due to carelessness, and sometimes due to a need to sample the food as it is being prepared.

The symptoms of tapeworm infections are usually mild, and it is usually a short segment wriggling around the rectum that gives it away. However there can be other complications from these worms, so donít forget to cook your meat!

Most travellers who pick up some sort of intestinal worm in the tropics do not become terribly ill. This is in part because the worms do not divide in humans, so if we only get infected with one worm, we stay with just one worm. In addition, most worms require in incubation period outside of our body, like a few weeks spent in some warm, moist soil. Considering that we have toilets year round, and snow for part of the year, these infections are not usually transmitted in temperate climates. Pinworm infections are an exception to these rules!

For more on parasites see: http://www.comeunity.com/adoption/health/parasites/

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© Copyright 2000 Dr. Mark Wise


Dr. Mark Wise is the director of The Travel Clinic (TM)) in Thornhill, Ontario, Canada and the Medical Director of The Travel Wise (TM) Clinic in Scarborough, Ontario, Canada. He is a family physician with training from the London School of Tropical Medicine in Tropical Diseases. He is a parent himself and often see potential adoptive parents in his clinic. Dr. Wise gives lectures and writes articles on the subject of travel medicine, for both medical and non-medical groups.

Adoption Health

Travel Health in Asia
Travel Health

Before You Go
Vaccinations for Southeast Asia

On the Road
Diarrhea
Jet Lag
Motion Sickness
Too Much Sun

Traveler's Diseases & Parasites
Malaria
Dengue
Honey - I Passed A Worm!
Parasites Outdoors
Tuberculosis (TB)
Rabies

Back Home
Upon your return

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Travel Precautions
Parasites
Scabies
Infectious Disease
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