Case of the Month - July 2010

A 32 year old Malawian immigrant to South Africa 8 years previously, travelled overland by bus through Mozambique and Zimbabwe back to Cape Town, having visited friends and relatives for a 2 week period in a village outside of Blantyre. He did not seek travel advice prior to his trip, nor did he receive pre-travel vaccinations or antimalarial prophylaxis whilst in Malawi. During his bus ride through Zimbabwe, he became unwell, with fever, rigors, headaches and nausea. He took paracetamol and delayed seeking medical advice until he arrived in Cape Town, 2 days later. At this stage, his symptoms continued and he had vomited twice. Having had 3 episodes of malaria before, he proffered this diagnosis to the private practitioner who saw him and an urgent blood sample was sent for a malaria rapid diagnostic test, full blood count, renal and liver function tests.

Haemoglobin g/dl	Total WBC x 109/L	Platelets x 109/L	Creatinine µmol/L	Bilirubin	ALT / AST IU/L	ALP IU/L
11.9	2.1	75	63	16	12 / 18	153

The rapid diagnostic test (RDT) for malaria was reported as a positive result for both the pan-malarial antigen and Plasmodium falciparum. He was prescribed Co-artem® (artemether-lumefantrine) and sent home. Three days later, his brother called to say that the patient had become confused and drowsy. He had continued vomiting and was unable to keep fluids or his Co-artem® down.

On admission to hospital, his Glasgow Coma Scale was 11/15 (E3, V3, M5), he was jaundiced, without hepatomegaly, but with a palpable spleen. There was no focal neurological deficit, but a suggestion of a reduction in the last few degrees of neck flexion. Investigations showed:

Haemoglobin g/dl	Total WBC x 109/L	Platelets x 109/L	Creatinine µmol/L	Bilirubin	ALT / AST IU/L	ALP IU/L
9.1	13.4	18	165	111	22 / 32	148

A thin blood film was prepared (figure 1), which revealed a 40% parasitaemia.

Figure 1.

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