Mosquito agitato

An 87 yo M brought in by son for complaints of generalized weakness/ malaise with intermittent “shaking” for 2-3 weeks prior to admission with history of returning from Liberia (West Africa) about 7 days ago after visiting family there. Labs notable for anemia with hyperbilirubinemia/ mild hemolysis with mild liver dysfunction and postive blood smears for Plasmodium Falciparum. PCP had prescribed him malaria prophylaxis with atovaquone-proguanil (unclear if was taking consistently).

Due to high clinical suspicion leading to prompt diagnosis, he was appropriately treated with artemether-lumefantine and recovered promtly without any complications.

Teaching points:

– prophylaxis needs be started 2-3 days prior to departure and continued for at least 7 days after return from endemic area (as the asymptomatic liver/ exoerythrocytic phase can persist for long time)

– suspect Malaria when patient presents with high fever (esp with rigors and cyclical nature) with hx of recent visit to an endemic malaria area

– understanding of the lifecycle is essential to understand pathophysiology and management rationale

– most malaria endemic areas are chloroquine-resistant and artemisinin derivatives with an addl agent like lumefantine is first line

– complications can be severe: encephalopathy, renal and hepatic failure, DIC with coagulopathy are a few to watch out for.

Slides.