Fever, headache, belly
pain
HPI
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37 yo Somali male was in his usual state of
health until 9 days ago he developed fever, HA
and body aches
Fever: not measured, some relief with Tylenol
but returns intermittently throughout the
day/night
Headache: bilateral and constant, worse in
temporal regions, no visual changes, having vivid
dreams, has a sore neck but not stiff, good ROM.
Abdominal pain- gassy bloating, poorly
localized, 6/10. Worse with meals, unclear
alleviating factors. Stooling with normal color,
frequency, and consistency. No nausea or
vomiting, eating normally up to today(now
anorexic).
HPI
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Two days later at work, he became weak and fell.
No trauma from fall - told to go home. Since then
he has been resting at home.
Sought medical attention at local ER 2 days ago
- says no tests were done and he was sent home
with Tylenol.
Symptoms acutely worsened last night and
developed a bloody nose, dark urine (like
coffee, “yellow eyes” per his sister.
Similar to what he had about 1.5 yrs ago while
in Uganda- was diagnosed with malaria and
given shots. Remained in Uganda 4-5 months
after treatment, but says when he arrived in USA
Jan 2006 he was tested negative for malaria.
Other Questions?
Past Medical History
 Malaria
– “several times in Somalia”,
“always goes away with medicine”
 Immigrant screening:
– RPR neg 9/06/05
– HIV ELISA neg 9/06/05
– ppD + to 19 mm, negative CXR,
prescribed INH. He only took ~3
months of INH
 No
medications or allergies
Social & Family history
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Arrived in Virginia in January 2006 from Somalia
via Uganda – never left MN since
Moved to MN March 2006 – never left since
Works in a Turkey packing plant with raw meats,
in Fairbault.
He lives in apartment with friends. His mother
and sister live in Mpls, other siblings in the US,
no children, not married.
Smokes tobacco cigarettes - half ppd. Denies
alcohol or other drug use ever.
FHX: noncontrib, except malaria while in africa
Physical exam
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General Appearance: NAD, thin.
BP 109/64 | Pulse 101 | Temp 102.6 | Resp 20 | Ht 5' 6" (1.68m) | Wt 137
lbs 2.0 oz (62.2kg) | SaO2 100%
Body Mass Index is 22.14 kg/(m^2).
HEENT: Normal- Head shows no signs of trauma or recent fall
-Eyes: Normal- EOMI, scleral icterus. Pupils equal and reactive to light.
-Nose: Normal- free of discharge.
-Mouth: Normal- No lesions present, throat is free of erythema, no tonsillar
enlargement. Fair dentition. Mucous membranes dry.
-Ears: Normal- Hearing grossly intact.
-Neck: Normal- No thyromegaly, no stiffness. Normal neck girth.
CARDIOVASCULAR: Normal- Regular rate and rhythm, normal S1/S2, no
murmurs, rubs or extra heart sounds. Pedal pulses intact, no JVD, no edema,
no carotid bruit
LUNG: Normal- Lungs show no wheezes, crackles or course lung sounds.
Chest excursion normal
ABDOMEN: Normal- BS present. No organomegaly. Tender in RUQ and
epigastric area, no rebound or guarding. No abdominal scars.
MUSCULOSKELETAL: Normal- No joint erythema, edema, or tenderness.
Muscles are nontender to palpation. Normal ROM.
LYMPHATIC/VASCULAR: Normal- No cervical, supraclavicular or axillary LAD.
SKIN: Normal- No rashes or lesions present, no bruising.
NEURO: Normal- Cranial nerves intact. Patellar and biceps reflexes intact.
Finger grip, triceps and biceps strength 5/5 bilaterally.
Physical exam
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General Appearance: NAD, thin.
BP 109/64 | Pulse 101 | Temp 102.6 | Resp 20 | Ht 5' 6" (1.68m) | Wt 137
lbs 2.0 oz (62.2kg) | SaO2 100% on RA
Body Mass Index is 22.14 kg/(m^2).
HEENT: Normal- Head shows no signs of trauma or recent fall
-Eyes: Normal- EOMI, scleral icterus. Pupils equal and reactive to light.
-Nose: Normal- free of discharge.
-Mouth: Normal- No lesions present, throat is free of erythema, no tonsillar
enlargement. Fair dentition. Mucous membranes dry.
-Ears: Normal- Hearing grossly intact.
-Neck: Normal- No thyromegaly, no stiffness. Normal neck girth.
CARDIOVASCULAR: Normal- Regular rate and rhythm, normal S1/S2, no
murmurs, rubs or extra heart sounds. Pedal pulses intact, no JVD, no edema,
no carotid bruit
LUNG: Normal- Lungs show no wheezes, crackles or course lung sounds.
Chest excursion normal
ABDOMEN: Normal- BS present. No organomegaly. Tender in RUQ and
epigastric area, no rebound or guarding. No abdominal scars.
MUSCULOSKELETAL: Normal- No joint erythema, edema, or tenderness.
Muscles are nontender to palpation. Normal ROM.
LYMPHATIC/VASCULAR: Normal- No cervical, supraclavicular or axillary LAD.
SKIN: Normal- No rashes or lesions present, no bruising.
NEURO: Normal- Cranial nerves intact. Patellar and biceps reflexes intact.
Finger grip, triceps and biceps strength 5/5 bilaterally.
Laboratory Data
135
107
11
70
4.0
24
0.8
INR 1.2
ALT 62 (10-40)
Alb 2.8
Alk Phos 149 (34-104)
Ca 7.7
MCV 87
12.9
3.9
AST 65 (10-42)
17
MCH 29.7
MCHC 34.2
37.7
RDW 14.1
Differential:
56% N
0% Eos
15% L
22% Bands
6% M
1% Myelocytes
Total bili 5.9 (<1.6)
Dir Bili 2.6 (<0.3)
Lipase 35
UA:
SG 1.029, pH 6.0, 2+ prot, large
blood, urobilinogen increased, neg
LE, neg nit, WBC 2-5, RBC 0-2
Nasal swab neg Influenza A&B
Imaging
 CXR:
normal
 RUQ US: normal liver, gall bladder,
and biliary ducts.
Call from the lab……
Diagnosis?
P. Vivax - Thin Smear Appearance
 Gametocytes
– large oval +
scattered brown pigment +/Schuffner’s dots
 Ring stage – large chromatin dot(s)
+ ameoboid shape +/- Schuffner’s
dots
 Schizonts – large, 12-24 merozoites
+/- Schuffner’s dots +/- ruptured
Diagnosis
 Classical
microscopy – during
daylight hours
 PCR – send out to Mayo
 Binax rapid diagnostic test
– Falciparum or NOT
Plasmodium vivax
www.dpd.cdc.gov/dpdx