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Title : A 51 year-old male w/ Fever, altered mentality
Date : March 15, 2010
Contributed by

Young Eun Ha, M.D.
Division of Infectious Diseases, Samsung Medical Center

Patient History
Age/Sex A 51/Male
Chief complaint Fever with altered mentality
Present illness

A 51-year-old man was referred to Samsung Medical Center because of rapidly progressing mental deterioration following fever, anorexia, vomiting and general weakness which had been present for prior 2 weeks. 2 Months before presentation, he worked in Luanda, Angola doing tiling and painting for 1 month. Then, he came home via South Africa. Since home -coming, he has had intermittent fever without having any medical examination. Then, his symptoms progressed gradually with anorexia, vomiting, general weakness, and to rapid mental deterioration at the time of visiting to local hospital. After being transferred to SMC, he was intubated and admitted to Intensive-care-unit. Diagnostic work-up and therapeutic intervention were done at the same time.

Past medical history

The patient had diabetes mellitus for 10 years with glucose-lowering agents.

Physical examination

On physical examination, vital signs were BP 134/64 mmHg, HR 105 bpm, BT 39.5 C, RR 22/min. Mental status was semi-comatous. Glasgow-coma-scale was 9 points. Pupils were responsive to light. Head & neck, chest, heart exams were normal. On abdominal palpation, enlarged liver and spleen were palpated and he was anuric. Extremities were OK.

Initial laboratory findings

WBC 7490/uL (seg 73%, metamyelocyte 2%, atypical lymphocyte 1%) Hb 11.2g/dL, Hematocrit 33.3%, Platelet 10,000/uL ESR 29mm/hr CRP 21.74mg/dL Total bilirubin 31.2mg/dL, AST/ALT 96/68 U/L, ALP 103 U/L BUN 63.7mg/dL, Creatinine 1.40 mg/dL, LDH 919 IU/L Lactic acid 6.96 mol/L, Triglyceride 510 mg/dL ABGA : 7.565 – 25.7 – 76.5 – 18.1 - 96.2%

Radiologic findings

 
Question - ID Case of the Week ( March 15, 2010 )
What would be the most likely diagnosis?
 
Correct Answer

Cerebral malaria with Plasmodium falciparum and non-falciparum Plasmodium coinfection

 
Review

P. falciparum malaria is very rare in Korea and seen in only a small group of patients who have travel history to endemic area.  It can be much more acute and severe than malaria caused by other Plasmodium species. In Korea, rapid diagnosis of severe falciparum malaria is often difficult and may not be considered in the differential diagnosis of fever with altered mentality especially when history taking is impossible due to mental deterioration. At first we also couldn\'t get a precise information on the travel area and whether he had been on malaria prophylaxis.  Moreover, anti-falciparum malarial drugs are not readily available in Korea making such patients at a greater risk of poor outcome.

For the rapid diagnosis of malaria, we currently use a simple commercialized antigen detection kit based on detection of P. falciparum-specific LDH and pan-Plasmodium LDH. In our patient, the antigen test kit showed positive band for control , Pan Ag ( common to all species of Plasmidum ), an P. f Ag (specific for P. falciparum ). This means that the patient has either P. falciparum malaria alone or coinfection of falciparum and non-falciparum Plasmodium. But because blood smear showed mature trophozoites, schizonts, and gametocytes which are hardly seen in P. falciparum infection due to sequestration in microvasculature, we diagnosed him as coinfection of falciparum and non-falciparum Plasmodium.

 

The management of this patients were continuous renal replacement therapy for anuric ARF and lactic acidosis, plasma apharesis for severe parasitemia, and combination of antimalarial agents (Artemether with Quinidine) for 1 week.  He recovered completely except oliguric renal failure.  After mental recovery, he stated that he had taken mefloquine weekly in Africa but had not taken it after coming back to Korea.

 

The patient was referred back to local hospital for management and follow-up of renal failure.

 

 

 

 

 


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