Intended for healthcare professionals


Assessment and initial management of acute undifferentiated fever in tropical and subtropical regions

BMJ 2018; 363 doi: (Published 29 November 2018) Cite this as: BMJ 2018;363:k4766
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A three page printable guide to identifying fevers, including local disease prevalence, clinical and diagnostic testing

  1. Anurag Bhargava, professor; head; adjunct professor1 2 3,
  2. Ravikar Ralph, assistant professor4,
  3. Biswaroop Chatterjee, professor5,
  4. Emmanuel Bottieau, professor of tropical medicine6
  1. 1Department of Medicine, Yenepoya Medical College, Mangalore, Karnataka, India
  2. 2Center for Nutrition Studies, Yenepoya (Deemed to be University), Mangalore, Karnataka, India
  3. 3Department of Medicine, McGill University, Montreal, Canada
  4. 4Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
  5. 5Department of Microbiology, IQ City Medical College, Durgapur, West Bengal, India
  6. 6Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
  7. Correspondence to: A Bhargava

What you need to know

  • Malaria, arboviral infections (such as dengue), enteric fever, and bacterial zoonotic diseases (such as scrub typhus and leptospirosis) are common causes to consider in patients presenting with acute fever and no localising symptoms in tropical regions

  • A step-wise approach—with a careful interpretation of local disease patterns, possible exposures and risk factors, clinical features, and basic laboratory data—can help clinicians recognise specific diseases

  • Request testing for malaria and a full blood count in all patients with acute undifferentiated fever

  • Early presumptive antibiotic therapy may be started for suspected bacterial zoonoses if diagnostic confirmatory tests are awaited or not available, as these infections may progress rapidly into a life threatening illness with multi-system involvement

  • Treatment for enteric fever needs to account for increasing drug resistance, especially in South Asia

Acute undifferentiated febrile illnesses (AUFI) are characterised by fever of less than two weeks’ duration without organ-specific symptoms at the onset.1 These may begin with headache, chills, and myalgia. Later, specific organs may be involved. AUFIs can range from mild and self limiting disease to progressive, life threatening illness. A mortality rate of 12% has been reported in severely ill hospitalised patients in tropical regions.2

AUFIs are classified into malaria and non-malarial illnesses with the help of microscopy or rapid diagnostic tests for malaria.3 The overlap of epidemiological and clinical features often renders clinical diagnosis difficult. There is greater focus on non-malarial AUFIs with the decline of malaria in many regions of the world.4 They account for 20-50% of all fevers in children over 5 years of age and adults in Asia and Africa.5 Laboratory confirmation is difficult—in contrast to malaria and dengue, for which high accuracy rapid diagnostic tests are now available. Current guidelines do not comprehensively address undifferentiated infections, which can fuel indiscriminate use of antimalarials …

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