Safari Souvenir A Case Study about Malaria by Michelle LeBlanc

Patient History & Physical 49 year old man presenting to the Emergency Center with the following symptoms: 49 year old man presenting to the Emergency Center with the following symptoms: Fever of 39.4 o C Fever of 39.4 o C Vomiting for 2 days Vomiting for 2 days Neck and back pain Neck and back pain

Patient History & Physical - continued Returned from a trip to Nigeria, Africa two weeks prior Returned from a trip to Nigeria, Africa two weeks prior Claims to have been taking anti-malarial medications Claims to have been taking anti-malarial medications Presumptive Diagnosis = Malaria Presumptive Diagnosis = Malaria

Laboratory Results WBC (billion/L) 4.3 (4.4 – 10.1) RBC (trillion/L) 5.02 (4.31 – 5.48) Hemoglobin (g/dL) 13.8 (13.4 – 17.0) Hematocrit (%) 39.8 (40.1 – 50.1) Platelet (billion/L) 50 (11.3 – 14.5) Malaria Smear Plasmodium falciparum seen Blood Culture No growth

Questions to consider: How does malaria affect hematology results? How does malaria affect hematology results? What is the effectiveness of prophylactic (anti-malarial) drugs? What is the effectiveness of prophylactic (anti-malarial) drugs? What is the significance of the low platelet count? What is the significance of the low platelet count?

Blood Smear Findings Plasmodium falciparum rings have delicate cytoplasm and 1 or 2 small chromatin dots. Red blood cells (RBCs) that are infected are not enlarged; multiple infection of RBCs more common in P. falciparum than in other malaria species. Plasmodium falciparum rings have delicate cytoplasm and 1 or 2 small chromatin dots. Red blood cells (RBCs) that are infected are not enlarged; multiple infection of RBCs more common in P. falciparum than in other malaria species.

Treatment Patient was given 500 cc of IV bolus in EC Patient was given 500 cc of IV bolus in EC He received 2 does of Mefluquine He received 2 does of Mefluquine Tylenol was given as needed for pain Tylenol was given as needed for pain He was prescribed Deoxycyclin for 7 days He was prescribed Deoxycyclin for 7 days

Types of Malaria / Symptoms Plasmodium vivax Plasmodium vivax Plasmodium malariae Plasmodium malariae Plasmodium falciparum Plasmodium falciparum Plasmodium ovale Plasmodium ovale Fever Fever Chills Chills Headache / muscle ache Headache / muscle ache Nausea / vomiting Nausea / vomiting Kidney damage Kidney damage Coma Coma Death Death

Trasmission Malaria is transmitted via the bite of an infected mosquito of the Anopheles species Malaria is transmitted via the bite of an infected mosquito of the Anopheles species The parasite enters the bloodstream and travels to the liver where it will grow and mature The parasite enters the bloodstream and travels to the liver where it will grow and mature Symptoms appear in 8 days to several months when the parasite enters the red blood cells Symptoms appear in 8 days to several months when the parasite enters the red blood cells

Transmission

Risk Found in 40% of the world’s population in areas of Central and South America, Africa, India, SE Asia and the Middle East Found in 40% of the world’s population in areas of Central and South America, Africa, India, SE Asia and the Middle East Currently 12,000 cases are diagnosed in the United States each year Currently 12,000 cases are diagnosed in the United States each year million clinical cases occur each year worldwide million clinical cases occur each year worldwide

Hematological Complications Hemolysis due to increased osmotic and mechanical fragility of the erythrocytes Hemolysis due to increased osmotic and mechanical fragility of the erythrocytes Decreased platelet count (thrombocytopenia) is associated with the use of some anti-malarial drugs Decreased platelet count (thrombocytopenia) is associated with the use of some anti-malarial drugs

Drug Therapy with Quinine Quinine is one of the most commonly prescribed anti-malarial drugs Quinine is one of the most commonly prescribed anti-malarial drugs Quinine is the 2 nd most common agent implicated in drug induced thrombocytopenia Quinine is the 2 nd most common agent implicated in drug induced thrombocytopenia It’s effectiveness is questioned due to increasing multidrug resistant malaria phenotypes It’s effectiveness is questioned due to increasing multidrug resistant malaria phenotypes Patient probably did take his prescribed anti- malarial medication Patient probably did take his prescribed anti- malarial medication

Human Resistance to Malaria Hemoglobin S found in red blood cells of Sickle Cell Anemia Hemoglobin S found in red blood cells of Sickle Cell Anemia Hemoglobin F found in red blood cells of Thalassemia Hemoglobin F found in red blood cells of Thalassemia The red blood cells containing these abnormal hemoglobins are more prone to ingestion by macrophages. Thus malaria organisms are more readily removed from the blood stream. The red blood cells containing these abnormal hemoglobins are more prone to ingestion by macrophages. Thus malaria organisms are more readily removed from the blood stream.

Summary 49 year old man presented to the EC with flu-like symptoms and decreased platelet count after returning from Africa two weeks prior 49 year old man presented to the EC with flu-like symptoms and decreased platelet count after returning from Africa two weeks prior Claims to have taken “unknown” anti-malarial medications Claims to have taken “unknown” anti-malarial medications Blood culture found no growth but Plasmodium falciparum was found on blood smear review Blood culture found no growth but Plasmodium falciparum was found on blood smear review Patient released after 2 days with not follow-up required Patient released after 2 days with not follow-up required

References Images from DPDx – A web site developed and maintained by CDC's Division of Parasitic Diseases (DPD) Library.htm Last accessed on 11/05/04. Images from DPDx – A web site developed and maintained by CDC's Division of Parasitic Diseases (DPD) Library.htm Last accessed on 11/05/04. Library.htm Library.htm

Credits This case study was prepared by Michelle Leblanc, MT(ASCP) while she was a Medical Technology student in the 2004 MT Class at William Beaumont Hospital, Hospital, Royal Oak, MI.