A patient had been referred into hospital because they had a very high temperature, severe muscle and joint pains and headache, she has recently returned from a holiday in Thailand. The patient had attended a pre-travel clinic, been given the appropriate vaccinations including for typhoid and had taken her Malaria prophylaxis. When she was seen on the ward she had developed a rash on her chest. The team thought the patient might have typhoid or paratyphoid (the vaccine is 70% effective for typhoid but has no effect on
paratyphoid). They had excluded malaria with blood tests, which is an essential component of the management of any traveller with a fever who has returned from a country where malaria is endemic. The patient’s blood tests showed a profoundly low white blood cell count and a slightly low platelet count. The patient’s kidney and liver function was within normal ranges.