INFECTION

Case 19: Three Days of Fever

History
A 24-year-old man presents to his general practitioner (GP) with a fever. This has been pres-
ent on and off for 3 days. On the first day he felt a little shaky, but by the third day he felt very
unwell with the fever and had a feeling of intense cold with generalized shaking at the same
time. He felt very sweaty. The whole episode lasted for 2.5h, and he felt drained and unwell
afterwards. He had lost his appetite.
There is a previous history of hepatitis 4 years earlier, and he had glandular fever at the age of
18 years. He smokes 1520 cigarettes each day and occasionally smokes marijuana. He denies
any intravenous drug abuse. He drinks around 14 units of alcohol each week. He has taken
no other medication except for malaria prophylaxis. He denies any homosexual contacts. He
has had a number of heterosexual contacts each year but says that all had been with protected
intercourse. He had returned from Nigeria 3 weeks earlier and was finishing off his prophy-
lactic malaria regime. He had been in Nigeria for 6 weeks as part of his job working for an oil
company and had no illnesses while he was there.

Examination
He looks unwell. His pulse is 94/min; blood pressure is 118/72mmHg. There are no heart
murmurs. There are no abnormalities to find in the respiratory system. In the abdomen there
is some tenderness in the left upper quadrant. There are no enlarged lymph nodes.

INVESTIGATIONS
Normal

Haemoglobin 11.1g/dL 13.717.7g/dL

Mean corpuscular volume (MCV) 97fL 8099fL
White cell count 9.4 109/L 3.910.6 109/L
Neutrophils 6.3 109/L 1.87.7 109/L
Lymphocytes 2.9 109/L 1.04.8 109/L
Platelets 112 109/L 150440 109/L
Sodium 134mmol/L 135145mmol/L
Potassium 4.8mmol/L 3.55.0mmol/L
Urea 4.2mmol/L 2.56.7mmol/L
Creatinine 74mol/L 70120mol/L
Alkaline phosphatase 76IU/L 30300IU/L
Alanine aminotransferase 33IU/L 535IU/L
Gamma-glutamyl transpeptidase 42IU/L 1151IU/L
Bilirubin 28mmol/L 317mmol/L
Glucose 4.5mmol/L 4.06.0mmol/L
Urine: no protein; no blood; no sugar

Questions
What abnormalities are likely to be present in the blood film?
What is the most likely diagnosis?
What would be the appropriate management?
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ANSWER 19
There is a raised bilirubin with normal liver enzymes, a mild anaemia with a high normal
mean corpuscular volume and a low platelet count. This makes haemolytic anaemia likely.
The recent travel to Nigeria raises the possibility of an illness acquired there. The common-
est such illness causing a fever in the weeks after return is malaria. The incubation period is
usually 1214 days. Longer incubation periods occur in semi-immune individuals and per-
sons taking inadequate malaria prophylaxis.The mild haemolytic anaemia with a low platelet
count would be typical findings. Slight enlargement of liver and spleen may occur after a few
days in nonimmune patients with malaria.
The diagnosis should be confirmed by appropriate expert examination of a blood film.
The most important feature in this 24-year-old man is the fever with what sound like rig-
ors. He has no other specific symptoms. He looks unwell, with tachycardia and some ten-
derness in the left upper quadrant that could be related to splenic enlargement. Malaria
prophylaxis is often not taken regularly. Even when it is, it does not provide complete
protection against malaria, which should always be suspected in circumstances such
as those described here. The risk might be assessed further by finding which parts of
Nigeria he spent his time in and whether he remembered mosquito bites. Measures to
avoid mosquito bites such as nets, insect repellants and suitable clothing are an impor-
tant part of prevention.
He has no history of intravenous drug abuse or recent risky sexual contact to suggest HIV
infection, although this could not be ruled out. HIV seroconversion can produce a feverish
illness but not usually as severe as this. Later in HIV infection an AIDS-related illness would
often be associated with a low total lymphocyte count, but this is normal in his case. Other
acute viral or bacterial infections are possible but are less likely to explain the abnormal
results of some investigations.
The diagnostic test for malaria is staining of a peripheral blood film with a Wright or
Giemsa stain. In this case it showed that around 1 per cent of red cells contained parasites.
Treatment depends on the likely resistance pattern in the area visited, and up-to-date advice
can be obtained by telephone from microbiology departments or tropical disease hospitals.
Falciparum malaria is usually treated with quinine sulphate because of widespread resis-
tance to chloroquine. A single dose of Fansidar (pyrimethamine and sulfadoxine) is given at
the end of the quinine course for final eradication of parasites. However, there is increasing
resistance to quinine, and artemesinin derivatives are increasingly becoming the first-line
treatment for falciparum malaria. In severe cases hyponatraemia and hypoglycaemia may
occur, and the sodium here is marginally low. Most of the severe complications are associ-
ated with Plasmodium falciparum malaria. They include cerebral malaria, lung involvement,
severe haemolysis and acute renal failure.

KEY POINTS

No prophylactic regime is certain to prevent malaria.

A traveller returning from a malaria endemic region who develops a fever has
malaria until proven otherwise.
Treatment should be guided by advice from tropical disease centres.
If the malaria species is unknown or the infection mixed, treat as falciparum malaria.

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