Solve a diagnostic puzzle: This is the case of a real patient treated at a Boston-area hospital
One winter, Jean came into our hospital emergency room with yellow skin. He had been a healthy and active 7-year-old. Recently, Jean had accompanied his family on a trip to their home country of Ghana. They visited relatives, ate home-cooked food, and drank local water. During their one-month stay, none of them felt anything was wrong.
Two weeks after Jean came back to the United States, his muscles had started to ache all over. Suddenly one night, he became feverish, sweating through his clothes, his temperature rising to near 102 degrees Fahrenheit. His family brought him to his pediatrician. The pediatrician discovered the child had a sore throat, and, thinking Jean had a case of infectious mononucleosis, started him on amoxicillin.
At first, Jean got better on the antibiotics. His fever came down and his muscle aches improved. But a couple days later, the fever roared back. It had now been more than two weeks since the family had returned from Ghana. Jean stopped eating; he could not bear to swallow the antibiotics. He was moaning in discomfort and felt so weak that he could not get out of bed. His family called for an ambulance and he was rushed to the hospital.
There, his blood pressure was noted to be very low, and his heart was fluttering rapidly. The emergency room team started him on antibiotics. The boy drifted in and out of sleep, waking occasionally to nod his head. His skin had turned yellow. His platelets — the cells that prevent bleeding — were 10 times lower than normal. He was critically ill. A blood test confirmed his diagnosis.
What was Jean’s disease?
Dr. Edward T. Ryan, the director of Tropical Medicine at Massachusetts General Hospital, led the infectious disease team that consulted on Jean’s case. After drawing his blood and preparing a smear on a glass slide, the team saw swarms of parasites had infected almost a third of his red blood cells.
Jean was diagnosed with severe malaria, caused by the parasite Plasmodium falciparum and spread by mosquitoes in many tropical countries. This disease moves rapidly, and if diagnosed late, can be fatal. Several clues point to his diagnosis. The first is a high and recurrent fever. A patient returning from a malaria zone with fever should always be evaluated for this disease. American physicians frequently neglect to do so. Furthermore, the disease may not announce itself until weeks after a person comes home from vacation.
Other clues include jaundice — the development of yellow skin — which occurs when the parasites destroy red blood cells and spill the pigments, which discolor the body. The kidneys can fail. Platelet counts can drop. People can become drowsy and lethargic, especially if the parasite starts to infect the brain.
Malaria kills 1 million people every year worldwide; the incidence of the disease in the United States is highest among travelers returning from abroad. Half of these travelers, like Jean, are visiting family and friends in a country they consider home. Although Jean’s parents might have some immunity to the disease, their children may not.
“This is not a case of bad parenting,” Dr. Ryan said. “Instead, it’s simply not on the radar screen for families or even primary care physicians. Families need to take appropriate precautions when traveling to malaria zones, which may include using mosquito netting, DEET-containing insect repellants, and medications.” The federal Centers for Disease Control and Prevention’s website lists the necessary precautions people should consider before traveling to a particular country, even if it’s a country that is considered home.
Given Jean’s progressive symptoms, the team had little time to waste. The doctors started Jean on intravenous quinidine, a drug that poisons the malaria parasite. They also called the CDC in Atlanta to ask for the most potent malaria medicine available in the United States – artemisinin. Unfortunately, because the Food and Drug Administration hasn’t approved this drug, hospitals don’t carry it. Instead, artemisinin is made by the military at Walter Reed National Military Medical Center and stockpiled by the CDC throughout the country.
In Jean’s case, a shipment of the medicine was flown from JFK airport to Boston, reaching Jean when he most needed it. “In general, we try to get artemisinin to patients who need it within seven hours of the telephone call,” said Paul Arguin, chief of the Domestic Response Unit in the CDC’s Malaria Branch. That’s commendable for a drug that no company makes, that no hospital stocks, and that the FDA has not yet approved.
After receiving artemisinin, Jean’s blood was cleared of the parasite. Had recognition or treatment of the disease been delayed longer, the outcome could have been different.
Do you have your own medical mystery? Dr. Sushrut Jangi of Beth Israel Deaconess Medical Center can be reached at firstname.lastname@example.org.