Internal medicine 1 rotation

Case write-up 3 (infectious disorder)

Reem Sadeq Alsuraihi- U18100852

2022-2023
History

Demographics
 Initials: A.B
 MRN: 920059462
 Room number: 01-A
 Age: 42-year-old
 Gender: Male
 Nationality: Central African rep
 Marital status: married
 Occupation: employed
 Source of history: patient

Chief complaint
45 years old African male patient with known essential hypertension for past 10 years
presents with fever since 3 days, associated with chills, diaphoresis and fatigue.

History of presenting illness

A.B, a 45-year-old male, presented to the emergency department with a complaint of a
fever since 3 days with highest reading 39.1 ̊C. Patient had travelled to Nigeria for 2 months
and returned back to Dubai 5days ago and he experienced the same fever one month ago
and he was told that he has malaria but does not know the type. Patient said he was given
three injections for 3 days(does not know the name) and he took oral quinine for 3 days.
The patient also has generalized abdominal pain that started 3 days before the
presentation, and he rates the pain 4 out of 10. The pain started gradually and it’s the same
severity for most of the time. The pain It is not associated with trauma, and it not
aggravated by position or anything specific. Furthermore, nothing specific makes the pain
better. Along with the fever, the patient experienced chills and diaphoresis but there is no
sore throat, no runny nose, no discharge from the ear or ear pain, and no burning sensation
while urinating. The patient did not experience any shortness of breath, chest pain or chest
tightness, no palpitation, and no leg swelling. Moreover, he did not notice any weight
changes or changes in his appetite but feels more fatigued and tired than usual. The patient
denies any Nausea, vomiting, diarrhoea or bloody stool, and any yellowish discoloration in
the sclera or in his skin.

Review of systems
 Constitutional: Generalized fatigue, fever, no weight loss, no insomnia.
  Neurological: no headache,no hearing difficulty, no dizziness.
 Cardiovascular: No palpitations, no chest pain or chest tightness.
 Respiratory: No shortness of breath, no Hemoptysis, no Chest pain, no cough.
 Gastrointestinal: No nausea and vomiting, no diarrhea, no constipation.
 Genitourinary: no urinary frequency, no urgency, no dysuria.
 Musculoskeletal: No Muscle wasting, no Morning stiffness, normal gait.
 Endocrinological: no polyuria, no polydipsia, no dry mouth.

Past medical and surgical history

 Patient was diagnosed with hypertension before 10 years, and he is on losartan
50mg daily and natrilix 1.5mg daily.
 He has history of Covid-19, 3 months ago.

Family history
 No family history of similar complaint.
 Family history is non-contributory.

Social history
 He is living with his family.
 Patient does not smoke or consume alcohol.
 His diet is home cooked meals.
 Patient exercise regularly.

Physical examination

Vitals signs
 Temperature: 39.1 ̊C
 Pulse: 87bpm
 BP: 148/84
 RR: 18 breaths/min
 spO2: 100% on room air

Measurements
 Weight: 75 kg
 Height: 181 cm
  BMI: 22.89 kg/m2

General examination
 Patient was lying in bed and not in distress. Patient looks fatigue. No cyanosis,
muscle wasting, speech abnormalities, nail clubbing, tar stain, asterixis and no signs
of dehydration noted. He was connected to an IV line and was conscious, alert and
oriented.

Focused examination

On examination:

Respiratory:
- Equal air entry bilaterally with normal vesicular breath sounds and no wheezing
bilaterally.
- Normal abdominothoracic respiration pattern.
- All lung fields resonant on percussion with normal tactile fremitus.

Abdominal:
- The abdomen was soft and nontender.
- No masses felt on light and deep palpation. 
- no hepatomegaly or splenomegaly.
- negative rebound test and negative Murphey’s punch test.
- no abdominal bruit detected.

Cardio:
- chest looks symmetrical no scars and no deformities or abnormal shape.
- Normal location of apex beat with normal character.
- Normal heart sounds (S1 and S2) no murmurs or add sounds.

Neuro:
- Normal gait and there are no neurological deficits.
- Normal tone, power, and reflexes.
- No loss of sensation in periphery and normal cranial nerves examination.
- He is alert and oriented to person, place, and time.

Musculoskeletal:
- Normal range of motion. No rigidity.
Differential diagnosis
 Malaria
 Gastroenteritis
 Hepatitis
 Leptospirosis

Investigations

Lab investigations

CBC:
Result Value
WBC  6.8 10^3/uL
RBC  4.80 10^6/uL
Hgb  13.0 g/dL
Hct  39.3% (low)
MCV 81.9fL
MCH 27.1pg
MCHC 33.1g/dL
RDW  14.8% (high)
Platelet  120 10^3/uL (low)
MPV 9.6 fL
Neutrophils%  74.0%
Lymphocytes%  14.0%

Monocytes%  12.0%
MDW 38.00 (high)

PT PTT:
Result Value
Prothrombine time 15.0 (high)
INR 1.18 (high)
PT Control 13.3
APTT 38.7
APTT Control 35.8
AST/SGOT:
Result Value
SGOT(AST) 30U/L

Creatinine blood:
Result Value
Creatinine 1.2mg/dL
eGFR(CKD-EPI) 77.4mL/min/1.73m(2)

C-Reactive protein blood, Venous:

Result Value
C-Reactive protein 127.9mg/dL (high)

Urea Electrolytes:
Result Value
Sodium 132.0 mmol/L (low)
Potassium 3.8 mmoL/L
Chloride  95 mmol/L (low)
Bicarbonate 26.4 mmol/L
Urea 38 mmol/L
Anion Gap 10 mmol/L

Glucose, Random:
Result Value
Glucose random 83mg/dL (high)
Liver function test:
Result Value
Bilirubin, total 3.0mg/dL (high)
Alkaline phosphatase 71U/L
SGPT (ALT) 28U/L
Total protein 7.0g/dL
Albumin 3.4g/dL
Globulin 3.6g/dL (high)

Procalcitonin:
Result Value
procalcitonin 58.22ng/dL (high)

Malaria parasite:
Result Value
Malaria prep Positive
Plasmodium Falciparum Ring Form
PARASITEMIA% 1

SARS-COV-2 RNA PCR-SWAB Nasopharynx:

Result Value
SARS-COV-2 Not detected
RNA PCR-SWAB (negative)
Imaging

Chest x-ray
- Normal thoracic cage.
- Clear costophrenic angles.
- Lung appear Clear.
- Normal heart and mediastinum.
- No pleural effusion or pneumothorax.

ECHO scan
- Echo shows normal heart
- No vulvar problem
- No dilatation in any heart chamber.
- no pericardial effusion or intracardiac thrombus noted.

Interpretation
- History and physical: from the history the patient already have the same symptoms
one month ago and he diagnosed with malaria and now he comes with travel history
and typical malaria presentation (fever, abdominal pain, fatigue and chills) so all of
these makes me think of malaria.
- Labs: Inflammatory markers (CRP and Procalcitonin) are all elevated which means we
have an infection. WBCs levels was normal which tells that it’s not bacterial
infection, but it can be fungal infection. And as per WHO, malaria due to plasmodium
falciparum commonly present with jaundice bilirubin ≥3mg/ dl. Its common that
malaria can cause electrolyte imbalance that’s why this patient have hyponatremia
and hypochloraemia. And as the haematocrit is low in this case this indicate anaemia
which is common in malaria.
- Blood smear: from the blood smear its shows that its positive to Plasmodium
Falciparum parasite. 
Provisional diagnosis
- Malaria Falciparum

Management plan
My plan
- Order blood workup (CBC, CRP and PCT), electrolyte urinalysis, HbA1c, random
glucose, chest x-ray, liver function test, kidney function test and blood smear to
check for Plasmodium Falciparum.
- Admit the patient
- Start IV fluids
- Paracetamol IV for fever and body pain
- Sodium chloride, 500 ml, intravenous, once
- Start artesunate then coartem after the last dose of artesunate.
- Repeat FBC and parasite level in the next day
- Change antihypertensive drug into losartan 100mg daily and carvidelol 25mg twice
daily.
- Follow up in primary health care for hypertension
- Discharge the patient when the level of the malaria parasitaemia is very low and the
patent vitals become stable.

Follow up
Subjective: Patient feels better, and the fever subsided after first day of admission .
Objective: Vitals are stable and afebrile. The patient looks well and not in pain. CRP
decreased to the normal range. And the parasitaemia level is <0.1%. PCT decreased from
58.22 to 21.89.
Assessment: after the blood smear shows that this patient has malaria Falciparum and the
labs investigation confirmed this as well.
Plan: repeat PCT, CBC, LFT and malaria parasitaemia will be done on OPD once the patient
come for follow up, discharged the patient on antimalarial drug and antihypertensive.
Learning points

-In most cases, visitors to malarial regions have never been exposed to the parasites or have
lost their immunity if they left the endemic area; as a result, they are at extremely high risk
of developing a serious illness if they contract Plasmodium falciparum. This makes it crucial
to take into account malaria in any feverish patients who have a history of travel to regions
with the disease.
-Age and location affect how severe malaria presents clinically. Young children (ages two to
five) and pregnant women are particularly at risk for developing severe malaria in places
where the disease is endemic. After repeated infections, older children and adults develop a
partial immunity against febrile malaria episodes (but not to malaria infection), making
them less likely to have severe illness. If infected with P. falciparum, travelers to regions
where malaria is endemic who have never been exposed to the parasite are more likely to
develop a severe illness.
- Malaria recurrence can result from treatment failure (recrudescence), relapse, or
reinfection; these may be hard to identify from one another. Both relapsing and
recrudescent infections cause the symptoms of the disease to recur after it seems to have
subsided. Relapse happens within weeks or months, while recrudescence typically happens
within days or weeks. Recrudescence occurs when parasites are undiscovered in the
bloodstream as a result of inadequate treatment or a host immune response (or both). A
recurring episode of peripheral parasitemia results from the release of fresh blood stage
parasites after relapse from dormant parasite stages (hypnozoites) in liver cells.
- When symptoms suggestive of malaria are present and a diagnostic test for malaria is
positive, the diagnosis of malaria is unmistakably made. Rapid diagnostic tests and light
microscopy of blood smears are used as diagnostic methods. A conclusive diagnosis should
be made for patients with suspected malaria. If the initial diagnostic assessment is negative
and there is still a clinical suspicion of malaria, follow-up testing needs to be done every day
for two additional days.

Literature review

In African new-borns and young children, Plasmodium falciparum malaria frequently results
in the potentially fatal complication of anemia. When the bone marrow is unable to
compensate for the rapid elimination of erythrocytes, anaemia sets in. All malaria patients
typically have bone marrow suppression, and asymptomatic P. falciparum infection has also
been documented. Thus, the quantity of erythrocyte destruction prior to the restoration of
normal bone marrow function must be considered in order to explain why some malaria
patients experience severe anemia while others maintain normal or close to normal
haemoglobin (Hb). Anaemia can either progress fast with severe, acute hemolysis or take a
protracted, smouldering course with a relatively sluggish rate of erythrocyte destruction
when there is ongoing bone marrow suppression.

There are conflicting reports regarding how long bone marrow suppression lasts following a
malaria episode. While other research has demonstrated that bone marrow suppression is
quickly recovered after therapy, certain investigations have shown indications of
hypoproliferative erythropoiesis and dyserythropoiesis for weeks following treatment.

Patients with recent malaria and negative malaria microscopy had their blood drawn. To
distinguish between individuals with (1) no malaria, (2) recently cleared malaria, and (3)
persistent P. falciparum infection, the presence of the Plasmodium antigens, lactate
dehydrogenase (Optimal®), aldolase, and histidine rich protein 2 (Now malaria®) was
utilized. As indicators of erythropoiesis, plasma levels of soluble transferrin receptor (sTfR),
erythropoietin (EPO), and red cell distribution width (RDW) were assessed. As indicators of
inflammation, interleukin (IL) 10 and tumour necrosis factor (TNF) were utilized.
EPO and hemoglobin were linked (R = -0.36, P 0.001) despite the presence of malaria. Bone
marrow suppression, i.e., low RDW (P 0.001 vs. P = 0.56) and sTfR (P = 0.02 vs. P = 0.36), was
linked with persistent P. falciparum infection but not with recent malaria without residual
parasites. There was no correlation between bone marrow suppression and TNF- and IL-10
levels.
Complete parasite eradication during malaria treatment may stop anaemia from later
developing. Even though no parasites can be seen by microscopy, very anemic children may
benefit from antimalarial medication if antigen tests are positive.

Kuijpers, L. M., Maltha, J., Guiraud, I., Kaboré, B., Lompo, P., Devlieger, H., Van Geet, C.,
Tinto, H., & Jacobs, J. (2016). Severe anaemia associated with Plasmodium falciparum
infection in children: Consequences for additional blood sampling for Research.
Malaria Journal, 15(1). https://doi.org/10.1186/s12936-016-1356-9