Case of the Month - July 2010
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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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