Caleb Ward MB BChir, Children’s National Medical Center

The Case
A 13yo female who recently returned from West Africa presents to the ED with fever and malaise, raising concern for tropical diseases in addition to the garden-variety infectious processes we usually see.

Here’s How You Answered Our Questions:

Discussion:
Most of the attendees agreed that, in practice, the hepatotoxicity or antiplatelet effects of acetaminophen or an NSAID, respectively, would be unlikely to have clinical manifestations from a single dose. While the patient’s ultimate diagnosis may affect the choice of antipyretic if she needed multiple doses later on in her care, a single dose of either could be given in the ED without much concern for any adverse effects.

As was hinted at by the final poll question, there was concern that this patient had more going on than “just” malaria. A parasite load of 0.3% didn’t seem to fully account for the severity of the patient’s symptoms and laboratory abnormalities (which included anemia, thrombocytopenia, and hyponatremia). Other diagnoses were entertained, including typhoid fever, dengue fever, or Lyme disease. Our teaching attending, Sabrina Guse, reminded us all that the CDC’s website is an excellent resource for any patient with a history of recent travel, and would have been helpful in this case to help broaden the differential (see her comment here). After this discussion, several respondents admitted that, had they thought of these additional diagnoses, they would have considered adding antimicrobial coverage as well. But more on that in the denouement…

Denouement:
An Infectious Disease (ID) consult was called from the ED. The ID team felt that malaria was unlikely to be the sole cause for her presentation, as the parasitemia was too low to explain the severity of her clinical symptoms. Her symptoms and CBC findings (Hgb 10.4, plt 85) were felt to be most suspicious for malaria with concomitant typhoid fever. The thrombocytopenia and hyponatremia were concerning to ID for possible concomitant dengue or rickettsial disease. Her specific travel within Florida was not felt to increase her risk for Zika. She was started on empiric treatment with Malarone, ceftriaxone, and doxycycline. Her fever and abdominal pain resolved over twenty four hours, at which point the doxycycline was discontinued. Her stool studies were negative for S. typhi, but ID felt the clinical picture was sufficiently suggestive that he was discharged on a seven day course of ciprofloxacin. In addition he completed a three day course of Malarone.

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