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An 18-year-old female "gap-year" student presents to her GP with sudden onset of fever, myalgia and weakness. She complains of a little diarrhoea and a cough. She has recently returned (1 week ago) from a 3-month, overland trip in East and Central Africa. She took regular antimalarial prophylaxis throughout her travel overseas. She ate food locally and lived in local hotels and boarding houses. Her temperature is 37.9 °C with a pulse of 80 and her blood pressure is normal. Her lung fields are clear and abdomen soft – there is no evidence of an enlarged liver or spleen. There are the marks of mosquito bites around her ankles but no evidence of skin sepsis.
1. What significance should be placed on the information that she took her malaria prophylaxis?
It is possible to develop malaria after having taken propylaxis, although it does reduce the risk of infection substantially. Additional history is required to find out what prophylaxis was taken and whether it was appropriate for the region she travelled through. It would also be necessary to find out whether she stopped her tablets immediately after she left the malarious area.
2. Are there other important steps in the management?
Malaria is the most important as Plasmodium falciparum infection can be fatal.
3. How would you do this?
Thick and thin blood films should be examined by a competent microscopist. There are antigen-detection dipstick tests that can be very helpful in making a diagnosis.
4. What other possible diagnoses should you entertain?
There is very little to go on in this history and the examination is not very helpful. This is a common situation. As she has returned so recently, one should exclude typhoid and brucellosis. Sepsis following a urinary infection is possible. There are a wide range of viral infections to consider, including acute hepatitis A. This could also be the ‘Katayama fever’ stage of acute schistosomiasis.
5. List the investigations that you would order.
In addition to films for malaria and trypanosomiasis, blood, urinary and faecal cultures should be taken. Serum should be taken and saved for later. A full blood count and white cell count should determine the presence of neutrophils or eosinophils. Viral serology should include hepatitis A. Consider HIV testing. A sample of faeces should be taken for detection of parasitic ova and cysts. Serology should be performed for parasitic infections including schistosomiasis and filaria.
6. What is the most important infection to exclude?
The holiday is now over and the patient may be feeling very anxious. It is also important to call in specialist advice, so this patient should be referred to an infectious diseases or tropical diseases specialist.