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Resident PGY 3
Henry Ford Macomb
Evaluation of a patient in whom you suspect a tropical disease requires a thorough history. You must determine the timeline of travel as well the time course of symptom onset and progression. Determine geographic region of travel, mode of transport, sick contacts, animal exposure, insect bites, water sources, sexual contact, vaccine history, and prophylactic medications. What follows is a case of a patient who recently returned from a trip to Africa who was diagnosed with Malaria, as well as pertinent information regarding this disease. A 27 year old male presents to the ED complaining of fever/chills, body aches and headache that began in the evening two days prior, worsening in severity since onset. Fever and body aches are more severe at night. He has had 2 episodes of diarrhea which started today. He denies any vomiting, cough, abdominal pain, vision changes, or sore throat. Patient was on a mission trip to Nigeria and Zambia for 8 days, returning 15 days ago. He did not take prophylactic medications nor use an insect net during the trip, although he did receive his required vaccinations. Denies contact with anyone ill, however, he did visit a hospital in Africa. Patient was found to have a slight AKI and elevated liver enzymes. Infectious Disease was consulted, Malarial Smear was sent, and patient was discharged with prescription for Hydoxychloroquine as Henry Ford and surrounding pharmacies did not carry Mefloquine. Patient returned to the ED 7 days later, after completing the course of Hydroxychloroquine. States that he had felt better for several days, but symptoms then returned and worsened. Patient was noted to be tachycardic, with scleral icterus, and with worsened liver function tests compared to the prior visit. Repeat malarial smear sent, and patient was transferred to Henry Ford Detroit for further evaluation. Malaria smear was positive, and he was started on Atovaquone and Chloroguanide. Patient also tested positive for Parvovirus. Chikungunya, Dengue, Tb, HIV, EBV, CMV, typhii, paratyphii and G6PD were negative. The patient’s AKI resolved , scleral icterus resolved, and patient’s liver function returned to normal. Patient completed his course of Atovaquone and Chloroguanide, and was discharged after a 4 day hospital course. Malaria occurs throughout most tropical regions and is caused by multiple species: P. falciparum (sub-Saharan Africa, New Guinea, Haiti, Dominican Republic), P. vivax (Americas and western Pacific), P. knowlesi (Malaysia, Thailand, Myanmar, Philippines, Thailand). P. ovale and P. malariae (both also occur in Africa but are less prevalent). Annual worldwide Malaria deaths peaked at 1.82 million in 2004, and have declined to 445,000 as of 2016. In a sample of 7,000 returned travelers presenting with fever, between 1997 and 2006, 21% were found to have Malaria, with more than 50% of these cases being P. falciparum. More than 70% of cases of imported Malaria are in Americans born in other countries and who return home to visit friends and relatives. Preventing travelers from contracting Malaria consists of education regarding safe preventative measures, physical barriers, repellents, as well as chemoprophylaxis suited for the specific travel destination. A diagnosis of Malaria requires a thorough history and exam, specific lab testing, and consideration of alternative tropical and domestic causes. Treatment then varies depending on the Malarial species, concomitant illnesses, and patient demographics.
Gardner, Justin and Cronovich, Keith, "Malaria in Macomb, Michigan" (2019). Case Reports. 74.