Fever After Fun in the Bali Sun: the Souvenir You Don't Want
A Practical Guide with Cheat Sheets for Doctors on Shift
Ahhhh, Bali. Land of sun-drenched beaches, vibrant culture, and endless family fun. For many Australians, especially Western Australians, it's a home away from home. Families return with wonderful memories, beautiful photos, and maybe a few extra Bintang singlets. But sometimes, they also bring back an unwelcome souvenir: a fever.
The febrile child (or adult) just returned from Bali is a common scenario, but one that can spark a flurry of questions:
How far should we investigate?
What are we even looking for?
Is it something exotic, or just a viral infection with bad timing?
In Part 1, we explored the GREAT travel history—a simple, structured way to extract meaningful information from returned travellers.
In Part 2, we zoomed in on the syndromic approach: using clinical presentation, incubation periods, and geography to guide diagnosis and investigations.
Now, we bring it all together in the Bali Edition. This post is a compilation of all things useful:
The GREAT travel history cheat sheet (tailored to Bali)
A breakdown of common clinical syndromes, typical incubation periods, and recommended investigations
A summary of the most common confirmed infections among returned Aussie travellers, based on published data
GREAT travel history- Bali edition
Published data on infections from Bali.
Common things happen commonly. And these should be targeted first. But what’s common in Bali.
Sohail et. al. 2018 looked at the spectrum of illnesses among fever in returned travellers among Australians from Bali over a 5 year period. This is the summary of the most common clinical syndromes (in order of frequency) and identified infections within each clinical syndromes.
It’s interesting to note that animal bites (mainly monkey) were common and required rabies post-exposure prophylaxis (PEP), but no patients were pre-vaccinated and RIG availability in Bali was poor.
What is the risk of malaria in Bali?
Of note, this same study did not find any cases of malaria. It is actually really rare (non-existent could be a better word) in Bali, unless one has travelled to other endemic areas in Indonesia.
“A total of 464 patients met inclusion criteria. Gastroenteritis (119/464, 26%), systemic febrile illness (88/464, 19%) and respiratory tract infection (51/464, 11%) were the most common diagnoses. Dengue was the most common laboratory-confirmed diagnosis (25/464, 5%). No cases of malaria were identified.”
High risk areas for malaria transmission: Eastern Indonesia, including the provinces of Maluku, North Maluku, East Nusa Tenggara, Papua, and West Papua, as well as in rural areas of Kalimantan, West Nusa Tenggara, Sulawesi, and Sumatra.
Common Clinical Syndromes, typical incubation periods and suggested investigations
If the history, examination and clinical syndromes does not fit the infection profile for a particular geography, then you need to start thinking laterally. Perhaps, Bali was just a stopover. Or, an infection has triggered an autoimmune response. Maybe unmask a malignancy. You get the drift.
As always, I hope this is useful for you. Do drop me a note, comment or request if you have a topic you want to delve into further.
Key Takeaways:
Dengue is #1, but don’t miss the others (typhoid, leptospirosis, rickettsia)
Malaria? Rare in Bali, unless they went beyond
Monkey bites/ scratches →
The risk for rabies is lifetime. Most travellers do not take pre-exposure prophylaxis, and will have difficulty obtaining rabies post-exposure prophylaxis overseas, resulting in significant delays in appropriate treatment.
Herpes B virus from infected macaque monkeys (rare, fatal) → urgent prophylaxis with Aciclovir/ Valaciclovir
Syndromic approach + incubation period + Geography = less over-testing, more precision
References:
Sohail A, McGuinness SL, Lightowler R, Leder K, Jomon B, Bain CA, Peleg AY. Spectrum of illness among returned Australian travellers from Bali, Indonesia: a 5-year retrospective observational study. Intern Med J. 2019 Jan;49(1):34-40. doi: 10.1111/imj.13993. PMID: 29869360.
Masyeni S, Yohan B, Somia IKA, Myint KSA, Sasmono RT. Dengue infection in international travellers visiting Bali, Indonesia. J Travel Med. 2018 Aug 1;25(1):tay061. doi: 10.1093/jtm/tay061. PMID: 30113689; PMCID: PMC6118167.
Mills DJ, Lau CL, Weinstein P. Animal bites and rabies exposure in Australian travellers. Med J Aust. 2011 Dec 19;195(11-12):673-5. doi: 10.5694/mja10.11413. PMID: 22171863.
Geng Hu, Haijun Du, Yaning Liu, Guizhen Wu, Jun Han. Herpes B virus: History, zoonotic potential, and public health implications. Biosafety and Health 2022 Aug; 4(4):213-219. Available online: https://www.sciencedirect.com/science/article/pii/S2590053622000726#s0040
Thanks for sharing! What a fantastic educational series!!!