A 24-year-old African-American female college student with no significant past medical history presented to the emergency room with fever, lower abdominal pain and nausea without vomiting starting the day prior to admission. She noted that her menstrual period was slightly late, but otherwise the history obtained was non-contributory.
In the ED, she was found to be febrile (102 F) and tachycardic. She had an episode of vaginal bleeding while being evaluated. As a result, a pelvic examination was performed, which was unremarkable aside from scant blood in the vaginal canal and a closed cervix. Beta-HCG was obtained and was elevated at 784. Ultrasound of the abdomen and pelvis demonstrated a fetal sac in the uterus, but was otherwise within normal limits. Routine diagnostic testing was notable for a normal white blood count, normal hemoglobin, low platelets (92,000), normal kidney function (Cr 0.6), mild transaminitis (ALT 84, AST 72) and an indirect hyperbilirubinemia (TB 1.4, DB 0.3). Urinalysis demonstrated 5-6 WBCs, 9-10 RBCs, 10-12 epithelial cells, 1+ bacteria and trace leukocytes.
She was subsequently admitted to the medical service with the diagnosis of UTI and threatened abortion and was started on nitrofurantoin and IV fluids. Overnight, she spiked a high fever (104 F) with rigors. Morning laboratory investigations revealed a new leukopenia (WBC 2.8) and worsening thrombocytopenia (Plt 66,000). As a result, OB/Gyn was consulted for concern for possible septic abortion. They determined that it was an inevitable abortion and antibiotics were broadened. Given her worsening septic picture, infectious disease was consulted, a peripheral blood smear sent and doxycycline started for concern of ehrlichiosis. During the infectious disease evaluation, it is discovered that both the patient and her husband had recently traveled to Nigeria, her husband had been infected with malaria during their visit there, and she herself had developed a fever a day prior to returning to the USA and had become so ill en route that she presented to the emergency room directly from the airport.
Subsequently, the peripheral smear was reviewed by the ID attending in the laboratory and intracellular 'ear muff' shaped parasites consistent with Plasmodium falciparum were seen. As a result, the patient was diagnosed with uncomplicated malaria given no evidence of complications meeting criteria for severe malaria (namely, severe anemia, renal failure, ARDS, and hyperparasitemia). The CDC was contacted with respect to Artemisinin-based combination treatment. However, the decision was made to treat immediately with atovaquone/proguanil given that it was more readily available from an outside pharmacy than waiting for Artemisinin-based medication sent directly from the CDC. It was not until the third day of hospitalization that she received appropriate treatment. With anti-malarials, her clinical condition improved and she defervesced over the next 48 h. She was eventually discharged home after a six-day admission.
We conducted a retrospective case series of all patients with confirmed diagnosis of malaria from 2001 to 2012 at four Connecticut teaching hospitals (Waterbury Hospital, St. Mary's Hospital, Hospital of St. Raphael, & Griffin Hospital) in order to describe the demographics of imported malaria and to identify potential barriers to timely diagnosis and treatment.
Of a total of the fourteen patients, 54% were African, 23% American, 16% South Asian and 8% Hispanic. Most patients were foreign residents visiting the USA (54%), while the rest were USA citizens. A vast majority of patients were traveling in sub-Saharan Africa (73%, 9% India, 9% Pakistan, 9% Dominican Republic). Only a minority of patients took anti-malarial prophylaxis (22%). Symptoms began on average 3.1 days (range 1-8, SD 2.8) after arrival to the USA and patients presented to a healthcare provider on average 4.7 days (range 0-37, SD 12.1) after onset of symptoms. At the time of presentation, malaria was on the differential diagnosis in only half of cases and travel history was documented in only 69% of cases. Mean time to diagnosis was 2.9 days (range 0-12, SD 3.6). The vast majority of cases were due to P. falciparum (92%), while the remaining case was due to Plasmodium vivax. In general, parasite burden was low with 75% of cases with <=2% parasitemia.
Appropriate treatment was initiated in 93% of cases and mean time to treatment from time of presentation was 3.0 days (range 0-12, SD 3.6). Anti-malarial medications were available in the hospital pharmacy for only half of the cases. For these patients, treatment was administered promptly (mean 2.2 h, range 1-3 h). In cases where medications were not available in the hospital, there was a significant time delay between when the drug was ordered and when it was administered with 75% of patients receiving treatment >=8 h (mean 10.3 h, range 7-12 h) after it was ordered. In general, patients responded well to treatment. 71% were admitted to the hospital and only one case required ICU admission. Patients requiring inpatient admission were hospitalized on average for 3.2 days (range 1-7, SD 1.9).