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Travel Medicine Condition ClinicalClues Febrile lllnesses Malaria Paroxysmal fever (every 48 or 72 hours, depending on the species and may be continuous with P/asmodium falciparum), intraerythrocytic parasites, thrombocytopenia Dengue fever Acute onset of fever with chills, frontal headache, retro-orbital pain, myalgia, arthralgia; lumbosacral pain, gastrointestinal or respiratory symptoms, extensor surface petechiae; biphasic fever pattern ("saddleback"), severe fatigue, hemorrhage (dengue hemorrhagic fever), shock, encephalopathy Chikungunya fever Fever (abrupt onset up to 40 'C [104'F] with rigors with recrudescent episodes), maculopapular rash on the limbs and trunk is common, and smalljoint polyarthritis; rarely centralnervous system, myocardial, ophthalmologic, liver, or kidney manifestations; relapsing and chronic rheumatologic symptoms for months/years in some patients Zika virus Mosquito exposure in endemic areas; nonspecific symptoms of fever, rash, joint pain, and/ or conjunctivitis (asymptomatic in up to 80% of persons); less commonly Guillain-Ba116 syndrome, meningoencephalitis, myelitis Typhoid fever Prolonged fevel pulse-temperature dissociation, diarrhea or constipation, faint salmon- colored macules on the abdomen and trunk ("rose spots") Rickettsial infection Tick or flea exposu re, macu lopa pu lar or petechia I rash, eschar at the site of the inocu lating tick bite, lymphadenopathy, fever Coxiella infection (O fever) Animal contact, self-limited febrile illness common, atypical pneumonia, elevated aminotransferase levels Yellow fever Abrupt fever, headache, nausea, and vomiting; after brief remission, jaundice, kidney injury, coagulopathy, and shock Viral hepatitis High fever initially, then low-grade fever, fatigue and anorexia, hepatomegaly, dark urine, clay-colored stools Monon ucleosis synd rome So re th roat, feve r, ce rvica I lym p h ad en o pathy, sp I enomega ly, atyp ica I lym phocytes, (cytomegalovirus and Epstein-Barr virus) elevated a m inotra nsferase levels Brucellosis Zoonotic exposure, waxing and waning (undulant) fevel arthralgia, hepatosplenomegaly, depression Leptospirosis Conjunctival suffusion (erythema without inflammatory exudates), calf and lumbar spine muscle tenderness, aseptic meningitis, jaundice, kidney failure, acute high remittent fever in initial septicemic phase with brief decline before second immune phase Lyme disease Flu-like syndrome, expanding homogenous annular or target skin lesions (erythema migrans) may be accompanied by fever, arthralgias, bilateral Bell palsy Histoplasmosis Nonproductive cough, chest pain, fever Legionellosis Pneumonia, diarrhea, dry cough, progressive dyspnea, lymphopenia, thrombocytopenia, e levated a m i notra nsferase a nd lactate d ehyd rogenase leve ls

Condition ClinicalClues Febrile lllnesses Malaria Paroxysmal fever (every 48 or 72 hours, depending on the species and may be continuous with P/asmodium falciparum), intraerythrocytic parasites, thrombocytopenia Dengue fever Acute onset of fever with chills, frontal headache, retro-orbital pain, myalgia, arthralgia; lumbosacral pain, gastrointestinal or respiratory symptoms, extensor surface petechiae; biphasic fever pattern ("saddleback"), severe fatigue, hemorrhage (dengue hemorrhagic fever), shock, encephalopathy Chikungunya fever Fever (abrupt onset up to 40 'C [104'F] with rigors with recrudescent episodes), maculopapular rash on the limbs and trunk is common, and smalljoint polyarthritis; rarely centralnervous system, myocardial, ophthalmologic, liver, or kidney manifestations; relapsing and chronic rheumatologic symptoms for months/years in some patients Zika virus Mosquito exposure in endemic areas; nonspecific symptoms of fever, rash, joint pain, and/ or conjunctivitis (asymptomatic in up to 80% of persons); less commonly Guillain-Ba116 syndrome, meningoencephalitis, myelitis Typhoid fever Prolonged fevel pulse-temperature dissociation, diarrhea or constipation, faint salmon- colored macules on the abdomen and trunk ("rose spots") Rickettsial infection Tick or flea exposu re, macu lopa pu lar or petechia I rash, eschar at the site of the inocu lating tick bite, lymphadenopathy, fever Coxiella infection (O fever) Animal contact, self-limited febrile illness common, atypical pneumonia, elevated aminotransferase levels Yellow fever Abrupt fever, headache, nausea, and vomiting; after brief remission, jaundice, kidney injury, coagulopathy, and shock Viral hepatitis High fever initially, then low-grade fever, fatigue and anorexia, hepatomegaly, dark urine, clay-colored stools Monon ucleosis synd rome So re th roat, feve r, ce rvica I lym p h ad en o pathy, sp I enomega ly, atyp ica I lym phocytes, (cytomegalovirus and Epstein-Barr virus) elevated a m inotra nsferase levels Brucellosis Zoonotic exposure, waxing and waning (undulant) fevel arthralgia, hepatosplenomegaly, depression Leptospirosis Conjunctival suffusion (erythema without inflammatory exudates), calf and lumbar spine muscle tenderness, aseptic meningitis, jaundice, kidney failure, acute high remittent fever in initial septicemic phase with brief decline before second immune phase Lyme disease Flu-like syndrome, expanding homogenous annular or target skin lesions (erythema migrans) may be accompanied by fever, arthralgias, bilateral Bell palsy Histoplasmosis Nonproductive cough, chest pain, fever Legionellosis Pneumonia, diarrhea, dry cough, progressive dyspnea, lymphopenia, thrombocytopenia, e levated a m i notra nsferase a nd lactate d ehyd rogenase leve ls Novel coronaviruses (severe acute Flu-like syndrome prodrome, diarrhea, dry cough with progressive dyspnea, lymphopenia, respiratory syndrome ISARS], SARS- th rom bocytopen ia, e levated actate d ehyd rog e nase leve ls I

Condition ClinicalClues Febrile lllnesses Malaria Paroxysmal fever (every 48 or 72 hours, depending on the species and may be continuous with P/asmodium falciparum), intraerythrocytic parasites, thrombocytopenia Dengue fever Acute onset of fever with chills, frontal headache, retro-orbital pain, myalgia, arthralgia; lumbosacral pain, gastrointestinal or respiratory symptoms, extensor surface petechiae; biphasic fever pattern ("saddleback"), severe fatigue, hemorrhage (dengue hemorrhagic fever), shock, encephalopathy Chikungunya fever Fever (abrupt onset up to 40 'C [104'F] with rigors with recrudescent episodes), maculopapular rash on the limbs and trunk is common, and smalljoint polyarthritis; rarely centralnervous system, myocardial, ophthalmologic, liver, or kidney manifestations; relapsing and chronic rheumatologic symptoms for months/years in some patients Zika virus Mosquito exposure in endemic areas; nonspecific symptoms of fever, rash, joint pain, and/ or conjunctivitis (asymptomatic in up to 80% of persons); less commonly Guillain-Ba116 syndrome, meningoencephalitis, myelitis Typhoid fever Prolonged fevel pulse-temperature dissociation, diarrhea or constipation, faint salmon- colored macules on the abdomen and trunk ("rose spots") Rickettsial infection Tick or flea exposu re, macu lopa pu lar or petechia I rash, eschar at the site of the inocu lating tick bite, lymphadenopathy, fever Coxiella infection (O fever) Animal contact, self-limited febrile illness common, atypical pneumonia, elevated aminotransferase levels Yellow fever Abrupt fever, headache, nausea, and vomiting; after brief remission, jaundice, kidney injury, coagulopathy, and shock Viral hepatitis High fever initially, then low-grade fever, fatigue and anorexia, hepatomegaly, dark urine, clay-colored stools Monon ucleosis synd rome So re th roat, feve r, ce rvica I lym p h ad en o pathy, sp I enomega ly, atyp ica I lym phocytes, (cytomegalovirus and Epstein-Barr virus) elevated a m inotra nsferase levels Brucellosis Zoonotic exposure, waxing and waning (undulant) fevel arthralgia, hepatosplenomegaly, depression Leptospirosis Conjunctival suffusion (erythema without inflammatory exudates), calf and lumbar spine muscle tenderness, aseptic meningitis, jaundice, kidney failure, acute high remittent fever in initial septicemic phase with brief decline before second immune phase Lyme disease Flu-like syndrome, expanding homogenous annular or target skin lesions (erythema migrans) may be accompanied by fever, arthralgias, bilateral Bell palsy Histoplasmosis Nonproductive cough, chest pain, fever Legionellosis Pneumonia, diarrhea, dry cough, progressive dyspnea, lymphopenia, thrombocytopenia, e levated a m i notra nsferase a nd lactate d ehyd rogenase leve ls Novel coronaviruses (severe acute Flu-like syndrome prodrome, diarrhea, dry cough with progressive dyspnea, lymphopenia, respiratory syndrome ISARS], SARS- th rom bocytopen ia, e levated actate d ehyd rog e nase leve ls I CoV-2, Middle East respiratory syndrome IMERS-CoVI) Japanese encephalitis High fever, altered mentation, cranial nerve palsies Tick-borne encephal itis Biphasic course of fever, headache, malaise, arthralgias followed by neuroinvasive illness (meningitis, encephalitis, flaccid paralysis, cranial nerve palsies, seizures) Hemorrhagic fever viruses (Ebola, Fever, malaise, myalgia, vomiting, diarrhea, coagulation disorders, and bleeding Marburg, and Lassa) Rabies Paresthesias or pain at wound site, fever, nausea and vomiting, hydrophobia, delirium, agitation

CoV-2, Middle East respiratory syndrome IMERS-CoVI) Japanese encephalitis High fever, altered mentation, cranial nerve palsies Tick-borne encephal itis Biphasic course of fever, headache, malaise, arthralgias followed by neuroinvasive illness (meningitis, encephalitis, flaccid paralysis, cranial nerve palsies, seizures) Hemorrhagic fever viruses (Ebola, Fever, malaise, myalgia, vomiting, diarrhea, coagulation disorders, and bleeding Marburg, and Lassa) Rabies Paresthesias or pain at wound site, fever, nausea and vomiting, hydrophobia, delirium, agitation Travelers' Diarrhea Bacterial agents: Escherichia coli, Abrupt onset, crampy diarrhea, blood in stools Ca m pyl obacter specie s, Sal monel I a species, Vibrio species, Shigella species Viral agents: rotavirus, norovirus Closed setting (such as cruise ship or classroom)acquisition, vomiting, diarrhea, short duration Protozoa : Cry pto spo ridium specieg Gradual onset, progressive and prolonged diarrhea, foul-smelling and greasy stools, microsporidia, Giardia speciet Entamoeba mucus or visible blood in stools histolytica, and /sospora species 61