Approach to Recent Immigrant with Pallor and Fatigue

Immediate Life-Threatening Exclusions

The American Society of Tropical Medicine and Hygiene recommends obtaining three thick and thin blood films over 72 hours and/or rapid diagnostic test (RDT) immediately, as malaria accounts for 22.2% of all febrile illness in travelers from tropical regions and 67.7% of tropical diseases 1, 2
The Centers for Disease Control and Prevention (CDC) guidelines suggest that malaria must be excluded in any patient from endemic areas within the past year, even without fever, as chronic malaria can present with pallor and fatigue alone 2
The World Health Organization (WHO) recommends treating empirically if high suspicion exists and the patient appears ill, even with initial negative tests 2

The American College of Physicians recommends checking platelet count, as thrombocytopenia suggests dengue, malaria, or other tropical infections 2

The Infectious Diseases Society of America (IDSA) guidelines suggest testing for visceral leishmaniasis with serology and considering bone marrow examination if hepatosplenomegaly is present, as this is endemic in the Horn of Africa 3, 4
The CDC recommends screening for enteric fever with blood cultures, as this accounts for 2.3% of febrile travelers and can present with chronic fatigue 1, 4

The American Association for the Study of Liver Diseases (AASLD) recommends obtaining liver function tests and renal function tests to evaluate for organ involvement from chronic infections 2
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) suggests checking for proteinuria and hematuria on urinalysis 2
The CDC recommends testing for anti-HAV IgM, HBsAg, anti-HCV, and anti-HEV IgM, as viral hepatitis accounts for 1.1% of febrile travelers 1, 3
The IDSA guidelines suggest obtaining extended blood cultures and serology for brucellosis if there is history of contact with livestock or consumption of unpasteurized dairy products 3, 4

The WHO recommends never assuming simple nutritional anemia without excluding infectious causes first, as 72.8% of sub-Saharan immigrants had at least one pathogenic infectious disease is not a cited fact, however, the CDC suggests not delaying malaria testing even in the absence of fever, as chronic malaria can present with isolated pallor and fatigue 2
The CDC recommends alerting laboratory staff when suspecting infections that pose occupational hazards such as brucellosis or tuberculosis 2

The IDSA guidelines suggest considering empiric antimalarial therapy if clinical suspicion is high and patient appears ill while awaiting confirmatory testing 2