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Original article
Etiology and outcome of febrile children coming from the tropics
Etiología del síndrome febril en el niño proveniente del trópico
David Torres-Fernandeza,
Corresponding author
, Luis Manuel Prieto Tatoa,b,c, Ana Perez-Ayalab,d, Cinta Moraledaa,b,c, Elisa Fernandez Cookea,b,c, Daniel Blazquez-Gameroa,b,c, Pablo Rojoa,b,c, Alfredo Perez Rivillab,d, Cristina Epalzaa,b,c
a Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Spain
b Instituto de Investigación 12 de Octubre (imas12), Spain
c Red de Investigación Traslacional en Infectología Pediátrica (RITIP), Spain
d Department of Microbiology, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">According to the United Nations World Tourism Organization&#44; there were nearly 1400 million international travels in 2017&#44; and tourism has grown at around 4&#37; per year for eight straight years&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> International travelers have grown significantly over the last years&#44; as well as imported diseases from tropical areas&#46; Children may imply up to 10&#37; of travelers&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">2&#44;3</span></a> It is assumed that children are more frequently sick than their caregivers while traveling&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a> The commonly named &#8220;Visiting Friends and Relatives&#8221; &#40;VFR&#41; group acquires special importance as it has been described that VFR children present more probability to travel without pre-travel consultation and proper preventive measures&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a> Besides the growth of international travelers&#44; the number of migrants is also increasing&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Information about medical problems in children coming from the tropics is scarce&#46; Reports are mainly based on single center studies of specific population groups such as admitted patients or travel consultation centers&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">4&#44;5&#44;7&#8211;11</span></a> The most frequent consultation reasons are diarrhea&#44; fever and dermatologic complaints&#44; which vary according to regions of origin&#46; Even if they are usually mild common infections&#44; potentially severe and deadly diseases&#44; such as malaria&#44; may underlie a febrile syndrome&#46; Consequently&#44; more studies are required to analyze this specific situation&#46; Our objective is to describe the demographic and clinical characteristics of febrile children coming from the tropics in a tertiary European hospital&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">Retrospective review of patients under 18 years old presenting with fever &#40;axillary temperature<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>38<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; at a tertiary Spanish hospital and surrounding primary health care centers&#44; between July 2002 and July 2018&#44; with a stay in a tropical region during the previous year&#46; Due to the absence of a specific diagnostic code in our hospital&#44; patients were selected from microbiological charts of thick smears for malaria or dengue serologies from the Microbiology and Parasitology Department&#46; In all cases in which a thick smear was performed&#44; an immunochromatographic assay was also done &#40;<span class="elsevierStyleItalic">Plasmodium falciparum</span> Histidine Rich Protein II&#44; and pan-malarial antigen detection&#46; BinaxNOW&#44; Alere&#41;&#46; <span class="elsevierStyleItalic">Plasmodium</span> species were differentiated doing a thin smear&#46; Additionally&#44; in some cases&#44; realtime polymerase chain reaction &#40;PCR&#41; for detection and differentiation of <span class="elsevierStyleItalic">Plasmodium</span> species &#40;RealStar Malaria Screen &#38; Type PCR Kit 1&#46;0&#46; Altona Diagnostics&#41; was performed&#46; For Dengue testing&#44; an immunochromatographic assay &#40;Dengue Duo&#44; Bioline&#44; SD&#41; for NS1 antigen&#44; IgM and IgG antibodies detection was used&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Data were collected from clinical records and organized attending to five aspects&#58; epidemiology and demographics&#44; travel-related information&#44; Health Care assistance&#44; clinical data and exams performed&#46; Initially diagnosed syndromes were grouped on the 21 groups described by Freedman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a> Qualitative variables are shown as percentages&#44; and quantitative variables as median and interquartile range&#46; Chi-squared test and Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test were used respectively for hypothesis tests&#46; Database was made on Microsoft Access 2013&#174;&#44; with appropriate coding procedure to ensure patient confidentiality&#46; Statistical analysis was performed with IBM&#174; SPSS&#174; Statistics v24&#46; Missing data was not considered into analysis&#46; This study was approved by the local Research and Ethics Committee&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0025" class="elsevierStylePara elsevierViewall">Between July 2002 and July 2018&#44; 202 episodes in which thick smears for malaria and&#47;or dengue serologies were performed in children were collected&#46; Fourteen cases did not fulfill the inclusion criteria&#46; Finally&#44; 188 episodes were analyzed&#44; 6 of them corresponded to a second event after another trip in the same patient&#46; Thick smear was performed alone in 157 patients&#44; dengue serology alone in 10 patients&#44; and both tests were done in 21 patients&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Epidemiology&#44; demographics and travel-related information</span><p id="par0030" class="elsevierStylePara elsevierViewall">Half of the patients were girls &#40;100&#47;188&#44; 53&#46;2&#37;&#41; and the median age was 3&#46;0 years old &#40;IQR 1&#46;5&#8211;8&#46;0&#41;&#46; The country of birth was mainly Spain &#40;99&#47;188&#44; 52&#46;7&#37;&#41;&#44; followed by Equatorial Guinea &#40;48&#47;188&#44; 25&#46;5&#37;&#41; and Nigeria &#40;4&#47;188&#44; 2&#46;1&#37;&#41;&#46; Nevertheless&#44; regarding the ethnic group&#44; the large majority were not Caucasian &#40;182&#47;188&#44; 96&#46;8&#37;&#41;&#44; with a predomination of Sub-Saharan African &#40;104&#47;188&#44; 55&#46;3&#37;&#41; and Latin-American &#40;62&#47;188&#44; 33&#46;0&#37;&#41;&#46; Demographic characteristics of patients according to visited region are outlined in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The most frequent reason for traveling was VFR of children born in Spain &#40;89&#47;188&#44; 47&#46;3&#37;&#41;&#44; followed by recently arrived migrants &#40;61&#47;188&#44; 32&#46;4&#37;&#41;&#46; Attending to the region in which the children stayed&#44; 54&#46;8&#37; &#40;103&#47;188&#41; came from Sub-Saharan Africa&#44; 29&#46;8&#37; &#40;56&#47;188&#41; from Latin America&#44; and 4&#46;8&#37; &#40;9&#47;188&#41; from Asia&#46; For travelers excluding migrants&#44; the median stay abroad was 4 weeks &#40;IQR 4&#46;0&#8211;8&#46;0&#41;&#44; and only 34&#37; &#40;64&#47;188&#41; of patients declared having consulted for pre-travel advice&#46; From 188 patients&#44; 149 &#40;79&#46;3&#37;&#41; had arrived to Spain in the previous 3 months&#44; 12 &#40;6&#46;4&#37;&#41; between 3 to 6 months&#44; and in 27 cases &#40;14&#46;4&#37;&#41; information was not available in clinical records&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Health care assistance</span><p id="par0040" class="elsevierStylePara elsevierViewall">The preferred service for first consultation was the hospital Emergency Department &#40;140&#47;188&#44; 74&#46;5&#37;&#41; while less than one fifth of patients attended first to a Primary Health Care center &#40;sending them afterwards to our hospital&#41;&#46; Globally&#44; 27 patients &#40;14&#46;4&#37;&#41; had consulted at least once before to another physician without performing a thick smear or dengue serology&#46; Half of the children were managed as out-patients&#46; However&#44; 87 &#40;46&#46;3&#37;&#41; were admitted&#44; and 7&#46;4&#37; &#40;14&#47;188&#41; of them ended up in Pediatric Intensive Care Unit &#40;PICU&#41;&#46; Patients from Sub-Saharan Africa were significantly admitted more frequently than those coming from other regions &#40;57&#46;3&#37; vs&#46; 30&#46;8&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The median hospitalization stay was 4 days &#40;IQR 3&#46;0&#8211;7&#46;3&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; One patient &#40;1&#46;2&#37;&#41; died during admission&#44; but it was due to his congenital heart disease and not related to the stay in the tropics&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Clinical data and exams performed</span><p id="par0045" class="elsevierStylePara elsevierViewall">Globally&#44; the main complaint of patients &#40;155&#47;188&#44; 82&#46;4&#37;&#41; was fever &#40;the rest of the patients&#44; though they have had fever&#44; their principal reason for consultation was a different symptom&#41;&#46; More than half of patients &#40;106&#47;188&#44; 56&#46;4&#37;&#41; presented a febrile syndrome without source&#44; followed by respiratory tract infections &#40;29&#47;188&#44; 15&#46;4&#37;&#41; and acute diarrhea &#40;22&#47;188&#44; 11&#46;7&#37;&#41;&#46; Differences between regions can be seen in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The most frequent final diagnoses are outlined in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; Malaria was the main cause &#40;39&#47;188&#44; 20&#46;7&#37;&#41;&#44; though in nearly a quarter of the cases&#44; no specific etiology was identified &#40;45&#47;188&#44; 23&#46;9&#37;&#41;&#46; Physical examination was normal in 37&#46;2&#37; &#40;70&#47;188&#41; of patients&#44; but the most common finding was hepatomegaly and&#47;or splenomegaly &#40;33&#47;188&#44; 17&#46;5&#37;&#41;&#46; General appearance was only affected &#40;regular or bad&#41; in 20 patients &#40;10&#46;6&#37;&#41;&#46; Regarding the 14 patients that were admitted to PICU&#44; 12 had malaria &#40;8 of them had hyperparasitemia as the only severity criteria&#41;&#44; 1 had severe dehydration &#40;due to chronic diarrhea in an HIV-infected patient&#41;&#44; and in the other one&#44; sepsis was suspected without microbiological confirmation&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">From those 27 patients who had consulted at least once to a physician before performing a thick smear or a dengue serology&#44; almost a half &#40;13 patients&#44; 48&#44;1&#37;&#41; had significant final diagnosis that needed specific management&#46; From these 13 patients&#44; 5 had malaria &#40;18&#46;5&#37;&#41;&#44; 2 had pneumonia &#40;7&#46;5&#37;&#41;&#44; 2 non-typhi <span class="elsevierStyleItalic">Salmonella</span> bacteremia&#44; 1 dengue fever &#40;3&#46;7&#37;&#41;&#44; 1 visceral leishmaniasis&#44; 1 pyelonephritis&#44; 1 <span class="elsevierStyleItalic">Cryptosporidium</span> diarrhea&#46; The other 14 cases &#40;51&#46;9&#37;&#41; had minor diseases&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">From the 178 thick smears performed&#44; 39 were positive&#46; <span class="elsevierStyleItalic">Plasmodium falciparum</span> was identified in 34 cases&#59; <span class="elsevierStyleItalic">P&#46; malariae</span> in 2 cases&#59; and there were 3 mixed infections due to <span class="elsevierStyleItalic">P&#46; falciparum</span>-<span class="elsevierStyleItalic">P&#46; malariae</span>&#44; <span class="elsevierStyleItalic">P&#46; falciparum</span>-<span class="elsevierStyleItalic">P&#46; vivax</span>&#44; and <span class="elsevierStyleItalic">P&#46; falciparum</span>-<span class="elsevierStyleItalic">P&#46; ovale</span>&#46; <span class="elsevierStyleItalic">Plasmodium</span> polymerase chain reaction &#40;PCR&#41; was performed in 25 cases with no discrepancies with thick smear&#46; Median parasitemia at diagnosis was 2&#46;7&#37; &#40;IQR 0&#46;7&#8211;6&#46;4&#37;&#41;&#46; Median platelet count in patients with malaria was significantly lower than in negative patients&#44; 94<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>&#47;&#956;l &#40;IQR 57&#46;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>&#47;&#956;l<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>164<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>&#47;&#956;l&#41; vs&#46; 284&#46;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>&#47;&#956;l &#40;IQR 231&#46;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>&#47;&#956;l<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>359&#46;3<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>&#47;&#956;l&#41;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#46; There were no other hematological differences according to malaria diagnosis&#46; Patients in which hepatomegaly or splenomegaly was noted in physical exam&#44; presented more frequently malaria &#40;68&#46;4&#37;&#41; than other diseases &#40;31&#46;5&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; There were no coinfections with dengue&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Febrile syndrome after a stay in the tropics has been widely studied in adults but in pediatric population information is scarce&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">9&#44;12&#44;13</span></a> Most pediatric publications are focused on specific pathologies and population groups such as admitted patients or travel consultation centers&#46; Moreover&#44; this is the first study to our knowledge done in pediatrics in Spain&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The large majority of our population was Sub-Saharan African and Latin American&#46; Nevertheless&#44; globally&#44; more than a half of children were born in Spain which represents the second generation of migrants&#44; who usually travel to their country of origin &#40;VFR&#41;&#46; They represented the main reason for traveling in our study &#40;47&#46;3&#37;&#41;&#46; Consequently&#44; most visited regions were Sub-Saharan Africa &#40;54&#46;8&#37;&#41; and Latin America &#40;29&#46;8&#37;&#41;&#46; In other studies in children&#44; performed in travel clinics<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">5&#44;8&#44;10</span></a> or in Emergency Departments&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3&#44;14</span></a> tourism is the main reason for traveling&#44; which usually implies shorter lengths of stay and more urban and hygienic destinations than VFRs&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a> In our cohort&#44; the median stay in travelers is quite long &#40;4 weeks&#41;&#46; Pre-travel advice remains an uncommon practice&#46; Only 34&#37; of patients had previously consulted&#44; which agrees with previously published data&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a> In addition&#44; our study presents a considerable group of recent arrival migrants &#40;61 cases&#44; 32&#46;4&#37;&#41;&#44; a population less frequently described in reported studies&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Most of the patients chose Emergency Department for the first consultation&#44; and only 35 &#40;18&#46;6&#37;&#41; had contacted before with their primary care practitioner &#40;free of charge in Spain&#41;&#46; This rate is lower than the 39&#46;8&#37; described by Naudin et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a> probably due to the proportion of recent migrants in our cohort&#46; Globally&#44; 27 patients &#40;14&#46;4&#37;&#41; had consulted previously in Emergency Department&#44; primary health care center&#44; or elsewhere without a thick smear or dengue serology performed while at risk of these diseases&#46; This emphasizes the need for reinforcing the training of first line physicians on this issue&#46; More than half of patients &#40;52&#46;1&#37;&#41; were managed as out-patients and&#44; when admitted&#44; hospitalizations were short&#46; However&#44; some of them presented severe diseases and 14 cases &#40;7&#46;2&#37;&#41; ended up in PICU&#44; mainly for malaria&#46; Hospitalization rate &#40;46&#46;2&#37;&#41; observed was higher than that reported in previous studies on Emergency Departments &#40;20&#8211;21&#37;&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3&#44;14</span></a> possibly because of the patients selection method&#46; Some mild cases in which blood test were not performed may have not been detected and managed as out-patients&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Most of the diagnosed pathologies corresponded to mild and common infections as it is shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; Malaria is the first identifiable cause&#44; which has also been reported as the primary cause of febrile syndrome in children and adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">7&#44;8&#44;10</span></a> No specific etiology was identified in 23&#46;9&#37; of patients&#44; similar to 20&#8211;30&#37; previously published rates in children&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3&#44;7</span></a> but higher than 8&#46;2&#8211;24&#37; adult records&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">9&#44;15</span></a> This highlights the difficulty of the differential diagnosis in children coming from the tropics&#44; where common viral infections are frequent but clinically not very different from infections important to identify&#44; such as malaria&#46; Globally&#44; physical examination was usually normal and general appearance was not altered&#46; Nevertheless&#44; finding hepatomegaly&#44; splenomegaly and bad clinical status were risk factors for admission in pediatric ward or PICU&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Clinical syndromes distribution varies depending on the region of interest&#46; A study from United Kingdom<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a> showed a predominance of diarrhea&#44; enteric fever and malaria due to <span class="elsevierStyleItalic">P&#46; vivax</span> based mainly on Indian subcontinent patients&#46; In a report from Australian travelers to mainly Southeast Asia and Oceania regions&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> upper respiratory tract infections&#44; systemic febrile illness and diarrhea accounted as the most frequent diagnosis without malaria cases&#46; On the other side&#44; French literature and subgroups of global studies from Sub-Saharan Africa and South-America exhibit a spectrum of diseases closer to our results&#44; with respiratory infections&#44; diarrhea and <span class="elsevierStyleItalic">P&#46; falciparum</span> malaria leading the charts&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3&#44;8</span></a> However&#44; globally&#44; in most of studies&#44; diarrhea was the main illness&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3&#44;5&#44;7&#44;10</span></a> while in our study&#44; systemic febrile syndrome&#44; respiratory infections and diarrhea complete the majority of events&#46; In other studies&#44; dermatologic pathology &#40;including sunburn&#44; mosquito bites&#44; etc&#46;&#41; acquires an important place as one of the most frequent diseases after a stay in the tropic&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a> In our study&#44; as fever was an inclusion criterion&#44; we only found cases of abscesses&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Malaria was in our study the first individual cause of fever in the child coming from the tropics and the main specific cause of systemic febrile illness&#44; which agrees with previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3&#44;5&#44;8</span></a> We found a predominance of <span class="elsevierStyleItalic">P&#46; falciparum</span>&#44; and one third of patients were admitted to PICU &#40;12&#47;39&#44; 30&#37;&#41; for presenting severity criteria&#46; All these patients had satisfactory outcome&#46; PCR for malaria had been performed in 25 cases&#44; with no discrepancies with thick smear and immunocromatographic assay&#44; possibly because of small sample&#44; submicroscopic malaria is rare in children under 5 years old&#44; and that tests were requested based on clinical manifestations such as fever&#44; leaving aside the discrepancies of submicroscopic malaria described&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">16&#44;17</span></a> Lower platelet count was found in patients with malaria&#44; which has been also reported as a comorbidity&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">7&#44;18</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Some limitations may need to be taken into account&#46; First&#44; as there is no specific coding for fever in children coming from the tropics&#44; identification of potential cases was performed using indirect microbiological criteria&#46; This may result in underestimation of the total number of episodes&#44; though these could correspond to trivial infections as probably the severe cases would have frankly manifested&#46; Using thick smear charts may overestimate Sub-Saharan Africa population and malaria prevalence&#44; while little demand for dengue serologies in routine practice may underrepresent patients from South-America and Asia&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusion</span><p id="par0100" class="elsevierStylePara elsevierViewall">The most frequent causes of febrile syndrome in a child coming from the tropics were mild and common infections&#46; However&#44; potential risk of severe diseases such as malaria requires appropriate assessment and a high level of suspicion&#46; Malaria was the main specific cause of fever&#44; and a significant proportion of the patients were admitted to Pediatric Intensive Care Unit&#46; Only one third of travelers attended a pre-travel consultation&#46; More than 80&#37; of febrile children coming from the tropics attended directly the Emergency Room and 14&#46;4&#37; had visited another physician previously without any specific tropical assessment&#46; This information emphasizes the need for reinforcing the training about tropical diseases among first line physicians treating children&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Funding</span><p id="par0105" class="elsevierStylePara elsevierViewall">No funding was secured for this study&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">International travelers have grown significantly over last years&#44; as well as imported diseases from tropical areas&#46; Information in pediatric population is scarce&#46; We describe demographic and clinical characteristics of febrile children coming from the tropics&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective review of patients under 18 years old&#44; presenting at a tertiary hospital and surrounding primary health care centers between July 2002 and July 2018 with a stay in a tropical region during the previous year&#46; Patients were selected from microbiological charts of thick smears for malaria or dengue serologies&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">188 patients were studied&#58; 52&#46;7&#37; were born in Spain with a median age of 3&#46;0 years old &#40;IQR 1&#46;5&#8211;8&#46;0&#41;&#46; Main regions of stay were Sub-Saharan Africa &#40;54&#46;8&#37;&#41; and Latin America &#40;29&#46;8&#37;&#41;&#44; mostly for visiting their friends and relatives &#40;56&#46;3&#37;&#41;&#44; followed by recent arrival migrants &#40;32&#46;4&#37;&#41;&#46; Only 34&#37; of travelers attended pre-travel consultation&#46; More than 80&#37; of these febrile children attended directly the Emergency Room&#46; The most frequent diagnoses were febrile syndrome without source &#40;56&#46;4&#37;&#41;&#44; respiratory condition &#40;15&#46;4&#37;&#41; and acute diarrhea &#40;11&#46;7&#37;&#41;&#46; Around a half &#40;52&#46;1&#37;&#41; were managed as outpatients&#44; but 46&#46;2&#37; were hospitalized and 7&#46;4&#37; were admitted to Intensive Care Unit&#46; No specific diagnosis was achieved in 24&#37; of cases&#46; However&#44; 29&#46;7&#37; were diagnosed with malaria&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Children with fever coming from tropical areas were at risk of severe infectious diseases&#46; Malaria was diagnosed in one out of four and 7&#37; required admission in PICU&#46; This information emphasizes the need of reinforcing training about tropical diseases among first line physicians&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0005"
            "titulo" => "Introduction"
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            "titulo" => "Methods"
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            "identificador" => "abst0015"
            "titulo" => "Results"
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            "identificador" => "abst0020"
            "titulo" => "Conclusion"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los viajes internacionales han aumentado en los &#250;ltimos a&#241;os&#44; as&#237; como las enfermedades importadas&#46; Los datos en edad pedi&#225;trica son escasos&#46; El objetivo de este estudio es describir las caracter&#237;sticas cl&#237;nico-epidemiol&#243;gicas del ni&#241;o con fiebre que viene del tr&#243;pico&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Revisi&#243;n retrospectiva de pacientes menores de 18 a&#241;os que&#44; tras una estancia en zona tropical en el &#250;ltimo a&#241;o&#44; acuden con fiebre a un hospital terciario y centros de salud de &#225;rea entre julio de 2002 y julio de 2018&#46; Se seleccionaron a trav&#233;s de los registros de gotas gruesas o serolog&#237;as de dengue&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 188 pacientes&#46; El 52&#44;7&#37; hab&#237;an nacido en Espa&#241;a&#44; con edad mediana de 3 a&#241;os &#40;RIC 1&#44;5-8&#44;0&#41;&#46; Las regiones de procedencia del viaje fueron &#193;frica Sub-Sahariana &#40;54&#44;8&#37;&#41; y Latinoam&#233;rica &#40;29&#44;8&#37;&#41;&#46; Los motivos principales fueron visitar a allegados &#40;56&#44;3&#37;&#41;&#44; seguidos de inmigrantes de llegada reciente &#40;32&#44;4&#37;&#41;&#46; Solo el 34&#37; de los viajeros hab&#237;an realizado consulta pre-viaje&#46; M&#225;s del 80&#37; acudieron directamente a Urgencias&#46; Los diagn&#243;sticos m&#225;s frecuentes fueron s&#237;ndrome febril sin focalidad &#40;56&#44;4&#37;&#41;&#44; enfermedad respiratoria &#40;15&#44;4&#37;&#41; y diarrea aguda &#40;11&#44;7&#37;&#41;&#46; La mitad &#40;52&#44;1&#37;&#41; fueron dados de alta&#44; pero 46&#44;2&#37; fueron ingresados&#44; y el 7&#44;4&#37; requiri&#243; Cuidados Intensivos&#46; No se hall&#243; una etiolog&#237;a espec&#237;fica en el 24&#37; de los casos&#46; Sin embargo&#44; el 29&#44;7&#37; tuvieron malaria&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El s&#237;ndrome febril en un ni&#241;o procedente del tr&#243;pico puede implicar enfermedades graves&#46; Uno de cada cuatro tuvo malaria&#44; y el 7&#37; requiri&#243; cuidados intensivos&#46; Por ello&#44; es necesario reforzar la formaci&#243;n en enfermedades tropicales en los m&#233;dicos de primera l&#237;nea&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
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            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
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        "etiqueta" => "Fig&#46; 1"
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        "mostrarFloat" => true
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Syndrome group according to region&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Me&#58; median&#59; IQR&#58; interquartile range&#59; N&#47;A&#58; non-available data&#46;</p>"
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                  \t\t\t\t">47&#47;103 &#40;45&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#47;20 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">11&#47;103 &#40;10&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#47;56 &#40;7&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#47;20 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#47;A&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#47;188 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#47;103 &#40;0&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#47;56 &#40;1&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Clinical management &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Out-patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&#47;188 &#40;52&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&#47;103 &#40;41&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#47;56 &#40;67&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#47;9 &#40;77&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#47;20 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Admitted to pediatric ward&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#47;188 &#40;38&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&#47;103 &#40;44&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#47;56 &#40;30&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#47;9 &#40;22&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#47;20 &#40;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pediatric Intensive Care Unit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#47;188 &#40;7&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#47;103 &#40;12&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#47;56 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#47;A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#47;188 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#47;103 &#40;0&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#47;20 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Days of hospitalization &#40;only admitted patients&#41;&#44; Me &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;3&#8211;7&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;4&#8211;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;2&#8211;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;2&#8211;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#47;A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">If indicated&#44; attendance to follow-up consultation attendance &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95&#47;188 &#40;50&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&#47;103 &#40;48&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#47;56 &#40;66&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#47;9 &#40;44&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#47;20 &#40;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">All regions&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No etiological diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45 &#40;23&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Malaria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39 &#40;20&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Upper respiratory tract infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;11&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Probably acute viral gastroenteritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;7&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Probably viral tonsillitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;3&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acute otitis media&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Typical pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acute EBV infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bacterial gastroenteritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Typhoid fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bacterial tonsillitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Occult bacteremia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos