Dr Philip Botha, Infectious Diseases Specialist, Tygerberg Hospital
Dr Albie de Frey and Lee Baker – South African Society of Travel Medicine
We describe two clinical cases, one originating from South Africa and the other from Australia. Both cases demonstrate the importance of a good history including a good travel history, meticulous attention to detail and the importance of good laboratory facilities to back the clinical diagnosis.
A previously fit and healthy, self-employed, middle aged South African engineer was admitted to a private hospital on the Highveld. He presented with erratic ‘soft’ neurological symptoms including inconsistent disorientation for time and place, inappropriate humour and mildly anti-social behaviour drawing the attention of the nursing supervisor on night duty. He did not have any obvious motor loss. He complained about a headache and there was mention of a low grade fever. All other vital signs and physical examination were normal.
He had a history of admission for ‘cerebral malaria’ to the ICU of the same hospital approximately three weeks before. He spent about a week in ICU and responded well to IV Quinine followed by oral doxycycline for seven days. He did not require mechanical ventilation nor renal dialysis.
In the period in-between admissions he was well with normal behaviour only complaining of a degree of fatigue ascribed to his infection and stay in ICU.
It had been assumed that he had contracted Plasmodium falciparum malaria in Nampula, Mozambique but he had travelled to the north of Zimbabwe for business a few weeks earlier. There was no other travel history.
This resembled a similar case that had occurred previously. See Case 2.
A sixty year old Australian Camp manager returned to work on a mine in West Africa two months after being admitted to a hospital in Australia for what had been diagnosed as P falciparum malaria whilst on home leave.
He was a well controlled, known insulin independent diabetic and other than having lost approximately 10kg he was considered fit and well. The weight loss had been ascribed to his spat with malaria including a week long stay in ICU.
Approximately ten days after his return to site he presented to the mine clinic with confusion, memory loss and disorientation for time and place.
He was thought to have malaria again in spite of the absence of a documented fever and a negative malaria antigen test. He was sent to Johannesburg, South Africa for further investigation and management.
Question 1: What is your differential diagnosis in Case 1?Continue to Answer 1