Endemic to the United States | Nonspecific viral illnesses | None, except seasonality associated with some of respiratory viruses | Variable; usually 3–10 d | Ask about influenza, measles, varicella immunization | Variable |
| Acute diarrhea3 | Minimal | 1–10 d | Ask about specific activities (hiking, camping) for Giardia, Cryptosporidium, food (and ice) consumption for enteric pathogens, hepatitis A immunization status, and antibiotic use for Clostridium difficile, especially in older children | Bloody or nonbloody diarrhea; malaise, fever; may have dehydration, especially in younger children |
| Babesoisis (Babesia microti)4 | Northeast, upper Midwest | 1–4 wk | More common May–October; contact with ticks (Ixodes scapularis, also the vector for Lyme) or mice (white-footed mouse is primary reservoir) It is generally thought that ticks need to feed for >48 h to effectively transmit disease | Fever, chills, myalgias, nausea, headache, nonproductive cough; may also have jaundice Illness much more severe in asplenic patients, other immunocompromised hosts, or chronic heart, hepatic, or lung disease |
| Lyme (Borrelia burgdorferi)5 | Northeast, mid-Atlantic states, upper Midwest, Pacific coast | 3–30 d | More common late spring-summer months; contact with ticks (I. scapularis, also the vector for babesiosis) or deer (white-tailed deer is primary reservoir) It is generally thought that ticks need to feed for >48 h to effectively transmit disease | Stage 1: erythema migrans (EM) at site of bite, fever, malaise, myalgias, arthralgias, regional adenopathy Stage 2: multiple EM, cranial nerve palsies, meningitis, headache, AV block, myocarditis, oligoarticular arthritis Stage 3: more chronic neurological (encephalopathy) and arthritic (refractory joint pain) symptoms |
| Hantavirus6 | Southwest; other foci in Brazil, Argentina, Chile, China | 2–4 wk | Exposure to rodents (excreta), especially inside homes | Fever, nausea, shock, abdominal pain; conjunctival, central nervous system, or GI hemorrhages occur in one-third of patients. Death may result from renal failure or respiratory distress syndrome. |
| Murine typhus (Rickettsia typhi)7 | Texas Gulf Coast, California; also seen in Africa, southeast Asia, Mediterranean | 1–2 wk | Vector is the rat flea; reservoir = rodents. In suburban areas, domestic cats, opossums, and cat fleas maintain the life cycle | Fever, headache, rash in 20%–80% (pruritic, maculopapular, starting on trunk and spreading peripherally with sparing of palms/soles), arthralgia, cough, hepatomegaly G6PD patients are at risk for more severe disease |
| Rocky Mountain spotted fever (Rickettsia rickettsii)8 | Southeast, southern Midwest; over 50% of US cases from Oklahoma, Tennessee, Arkansas | 2–14 d | Tick exposure (Dermacentor = dog, wood ticks); most need to feed a minimum of 4–6 h to transmit disease | “Classic” triad of fever, rash, and headache seen in a minority of children; also may see myalgia, vomiting, abdominal pain, photophobia Rash after 2–5 d of fever: initially blanching erythematous macules on wrists/ankles, then spreads centrally and becomes petechial |
Almost exclusively imported | Amebiasis (Entamoeba histolytica)9 | Latin America, southern Asia, western/southern Africa | 2 d–4 mo, but can remain latent for years | Ask about water sources when traveling | Many patients may be asymptomatic, but should be treated to prevent invasive disease Colitis: several weeks of crampy abdominal pain, weight loss, watery, or bloody diarrhea Liver abscess: fever, cough, right upper quadrant pain, referred shoulder pain (more common in adults) |
| Chikungunya (togavirus)10 | Africa, India, southeast Asia | 1–12 d | Aedes mosquito; diagnosis made by excluding other diseases found in the same regions | Fever, headache, myalgia, acute and chronic arthralgia (symmetrical, multiple joints affected), rash (erythematous, petechial, erythroderma, or desquamation; often lasts 2–3 d, and does not spare palms/soles); seizures and neurologic complications more common in children |
| Cholera (Vibrio cholerae)11 | Most cases in Africa, Indian subcontinent, southeast Asia; outbreaks common after disasters (Haiti) | 2–5 d | Ask about drinking untreated water, eat poorly cooked or raw food (especially seafood), and where traveled with in a country | Most infections asymptomatic or with mild gastroenteritis Severe cases: painless, nonbloody rice-water stools, hypovolemic shock |
| E. coli O157:H711 | Worldwide; most US cases in southwestern, western, and northeastern states | 3–9 d | Linked to undercooked beef and a variety of vegetables | Watery diarrhea that becomes bloody after 1–5 d; severe abdominal pain, usually afebrile Hemolytic uremic syndrome (HUS) |
| Hemorrhagic fevers other than dengue (e.g., Ebola, Marburg)12 | Ebola: central/west Africa Marburg: west Africa Lassa: west Africa Also seen in South America (e.g., Argentinian, Bolivian, Venezuelan hemorrhagic fever | 2–21 d | Animal exposure: bats (Marburg), rodents (Lassa, South American hemorrhagic fevers); exposure to blood products (Ebola) | Fever, myalgia, headache, vomiting, diarrhea, abdominal or chest pain, mental status changes. Rash begins around day 5 (usually on trunk), progressing from erythema to petechiae as disseminated intravascular coagulation evolves |
| Leishmaniasis (Leishmania species, protozoa)13 | 90% of cases in Bangladesh, Brazil, Ethiopia, India, Nepal, and Sudan, but endemic in 70 countries | Weeks–months for cutaneous; months–years for visceral and mucosal | Transmitted by the phlebotomine sandfly, with domestic and stray dogs as reservoirs | Cutaneous (in 80% of travelers): papule progresses to nodule then ulcer (most common on face, extremities); painless, but locally destructive Visceral (= kala-azar): fever, weight loss, hepatosplenomegaly Mucosal: ulcerative lesions near nose and mouth, very locally destructive and disfiguring |
| Malaria (Plasmodium species, most importantly P. falciparum)14 | Central and northern South America, sub-Saharan Africa, southeast Asia and Indian subcontinent | 7–30 d | Vector = Anopheles mosquitoes (feed at dusk and at night) Ask about specific regions of travel (compare to CDC website) and ask if child received malaria prophylaxis during the trip | Fever, vomiting, headache, abdominal pain, malaise, jaundice; hepatosplenomegaly Fever in children returning from malaria-endemic areas should be considered malaria until proven otherwise |
| Rabies (rhabdovirus)15 | Most human cases occur in Africa, Asia, and the Indian subcontinent | 1–3 mo (longer incubation period for bites to distal extremities) | Most common reservoir in the United States is the bat due to high immunization rates in dogs, cats. Raccoons, skunks, foxes are other vectors domestically. Internationally, dogs are the most common vector, though described in a variety of mammals | Begins with neuropathic pain at site of infection, then fever and headache, progressing to altered mentation, hallucination, hydrophobia, aerophobia |
| Schistosomiasis (Schistosoma mansoni, hematobium, japonicum)16 | 85% of cases in Africa; others in Middle East, southeast Asia | 2 wk–3 mo (acute form), months–years (chronic form) | Swimming, bathing, and wading in contaminated freshwater; contact with infected snail vectors | Acute infection = Katayama syndrome: fever, headache, myalgias, diarrhea, cough, painful hepatosplenomegaly Chronic infection results from host immune response to schistosome eggs, which lodge in end organs and provoke an eosinophilic, granulomatous response, which may result in hepatic fibrosis, bladder calcification, and hematuria |
| Strongyloides (Strongyloides stercoralis, a nematode)17 | Endemic in Latin America, southeast Asia, sub-Saharan Africa | 3–4 wk | Immunocompromised hosts are at risk for hyperinfection, characterized by a high number of worms (especially in the lungs), or by worms in ectopic sites (e.g., the brain), or both | Skin: migratory, serpiginous urticarial rash (larva currens), most commonly involving perianal region and torso GI: anorexia, nausea/vomiting, bloating, abdominal pain Pulmonary: cough, shortness of breath |
| Typhoid fever (S. enterica serotype typhi)18 | Highest case rates in Indian subcontinent; also seen in Asia, sub-Saharan Africa, western South America | 1–4 wk | Ask about water supply (and if they received the oral typhoid vaccine) | Fever, chills, headache, malaise, abdominal pain, anorexia, transient rose spots (erythematous, blanchable), confusion, convulsions (more common in preschool-aged children. Complications include GI bleeding or perforation or typhoid encephalopathy |
| Yellow fever (Flavivirus)19 | Central South America, central Africa | 3–16 d | Vector = Aedes mosquitoes (feed morning and evening) | Most patients are asymptomatic. Most common symptoms: sudden-onset fever, chills, headache, back pain, myalgias, weakness. 15% progress to severe disease: jaundice, disseminated intravascular coagulation, multiorgan system failure |
Infections seen in US, but more common internationally | Campylobacter (C. jejuni)11 | Worldwide; one of the most common bacterial causes of diarrhea in the United States | 1–11 d (usually 2–4 d) | Contaminated or undercooked food (especially poultry) or water; contact with infected animals (especially kittens or puppies) | Diarrhea (often bloody), abdominal cramps, fever 1/1000 leads to Guillian–Barré; smaller percentages develop reactive arthritis or iritis |
| Cysticercosis (Taenia solium)20 | Central and South America, sub-Saharan Africa, Indian sub-continent and southeast Asia | Months–years | Pork consumption; vegetarians and persons not eating pork can acquire infection from fecal-oral contamination with eggs from carriers | Seizures for neurocysticercosis (lesions average 1–2 cm in diameter); visual loss if ophthalmic involvement; massive cyst burden in muscles can present at pseudohypertrophy |
| Dengue21 | Central and South America, Caribbean, southeast Asia; In US, cases reported in Florida, South Texas | 4–10 d | Vector = Aedes mosquitoes (feed morning and evening) | Stage 1: fever, headache, myalgia, transient rash, mild hemorrhagic manifestations Stage 2: systemic vascular leak with pleural effusions, ascites, hypotension; hemorrhagic manifestations most common Stage 3: recover phase starting 2–3 d after stage 2; may see pruritic maculopapular rashes |
| Leptospirosis (Spirochetes, several pathogenic species)22 | Worldwide distribution, higher incidence in tropical climates | 2–28 d | Contact with contaminated water (ask about swimming, rafting, kayaking) or exposure to urine or other body fluids of rodents, cattle, dogs, goats, horses, opossums, raccoons, rodents, swine, sheep Outbreaks have been seen after flooding | Fever, chills, headache, retro-orbital pain, myalgias, vomiting, abdominal pain, jaundice, conjunctival suffusion, rash |
| Salmonella, non-typhi23 | Most common bacterial cause of food-borne infections in the United States | 12–36 h | Many animal reservoirs (reptiles, poultry, pigs, cattle); ask about contaminated or undercooked food | Fever, diarrhea (may be bloody), cramping abdominal pain, vomiting Reactive arthritis and iritis occur in a small percentage as postinfectious phenomenon |
| Shigella (Shigella flexneri, sonnei)11 | Worldwide | 12 h–7 d (usually 1–3 d) | In addition to travel, also associated with daycare center attendance | Fever, diarrhea (may be bloody), crampy abdominal pain, vomiting Reactive arthritis and iritis occur in a small percentage as postinfectious phenomenon |
| Tuberculosis (Mycobacterium tuberculosis)24 | Worldwide, but 90% of burden is in developing nations. Over 50% of cases in US from New York, California, Texas, Florida | Weeks–months (shorter incubation in infants and immunocompromised children | Ask about tuberculosis contacts (families will rarely volunteer this) and about persons at risk for TB: homeless, incarcerated, HIV positive, previously treated for TB | Fever, malaise, cough; hemoptysis and night sweats rare in children Most common sites of extrapulmonary disease: lymphadenopathy and meningitis |