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The returning traveller

01 September 2011

Mr M, a 23-year-old builder, went on holiday to Thailand. His flatmate had been there and recommended that Mr M take malaria prophylaxis. Mr M went to a travel clinic to get some antimalarials and started to take them as prescribed before travelling. However, a few days after starting the course, he felt nauseous and unwell and decided to stop taking the medication.

He had an uneventful trip and returned home after a two-week holiday. One month later Mr M had a bad bout of diarrhoea. He then began to vomit and felt feverish. He put it down to having a fast food meal the previous evening but as things didn’t seem to be getting better 24 hours later, he made an emergency appointment to see his GP.

The GP, Dr H, took a history and ascertained that Mr M had eaten fast food two days previously, which could explain his diarrhoea and vomiting. Mr M mentioned to Dr H that he has been on holiday in Thailand a month before; however, Dr H didn’t make a note of the recent travel in the medical records. Mr M was advised to drink plenty of fluids and dioralyte and to come in if his symptoms didn’t settle over the coming week. Dr H wrote: “Possible food poisoning from meal out. Well hydrated” in the medical records.

Three days later Mr M came back to the practice because he felt significantly more unwell. He was seen by another GP, Dr J. His main symptom was malaise and shortness of breath. Dr J took a brief history, examined the chest and did basic observations. Dr J recorded that Mr M had a fever of 38.9° and a clear chest, and was coughing. Dr J explained management of an upper respiratory infection to Mr M and documented: “Flu-like symptoms. Increase fluids; add paracetamol.”

Ten days after the symptoms started, Mr M became more unwell and his flatmate called an ambulance for him. In hospital his flatmate mentioned the recent trip to Thailand and investigations were carried out accordingly.

A diagnosis of falciparum malaria was made. Unfortunately Mr M did not respond to treatment, deteriorated and died within a few days of admission. His family made a successful claim against both doctors involved for failing to establish the history of recent travel. It was settled for a moderate amount.

Learning points

  • Consider malaria in every febrile patient returning from a malaria-endemic area within the last year, especially in the previous three months
  • Ask the right questions for the presenting complaint. Patients need to be guided into giving a relevant history. A patient who was on a trip and develops symptoms a month later is unlikely to make an association.
  • Dr H recalled Mr M mentioning his holiday to Thailand, but he pursued a different diagnosis. When symptoms do not respond as expected, it is worth starting afresh with the history and considering alternative diagnoses.
  • Always be aware of tropical diseases when seeing a patient with fever and ask about recent foreign travel; nowadays exotic holiday destinations are common and tropical illness may present at any surgery.
  • Consider malaria in every febrile patient returning from a malaria-endemic area within the last year, especially in the previous three months, regardless of whether they have taken prophylaxis. Early treatment will improve prognosis and prevent deaths.
  • Even in countries where malaria is not endemic and the patient has not travelled, you should bear in mind that a patient need not have travelled abroad to become infected.

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