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Case of the Month - February 2019

RN E. Schoeman – Infection Prevention and Control (IPC) Manager at Mediclinic Panorama. Special thanks to RN K. Pienaar (Previous IPC Manager, Mediclinic Paarl) for assisting with some clinical information and to the patient for allowing us to share and learn from her story.

In October 2017, a 26 year old female patient was admitted via the emergency centre at the Health Care facility where she works as a Registered Nurse in the surgical unit. The Health Care Facility is located in the Northern suburbs of Cape Town, South Africa. The patient resides in Paarl, Western Cape. She presented to the emergency department with a fever (39,4˚C), nausea, vomiting, tachycardia, a throbbing headache and diminished sensation of her left arm. She had no other co-morbidities and was not pregnant at the time. She also did not have a recent travel history. On clinical examination no neck stiffness was observed and the chest was clear, however the abdomen was found to be tender. Blood cultures were done, however yielded no growth after 5 days. The urine analysis indicated the presence of blood and protein. Laboratory test included a C-reactive protein (CRP) of 26.9mg/L, Liver Functions Test (LFT) indicated a Gamma-Glutamyl Transferase (GGT) of 76 IU/L and an Alkaline Phosphatase (ALP) of 137 IU/L. On the Full Blood Count (FBC) the Haemoglobin (Hb) was 13,8g/dL, the White Cell Count (WCC) 8.0 x10E9/L and the Platelet count 271 x10E9/L. An ultrasound done of the gallbladder indicated no clear signs of cholecystitis. The patient was treated for flu with an antiviral drug, Oseltamivir (Tamiflu®) and antipyretic medication. She was admitted overnight for observation. The following day the patient was apyrexial and feeling better. The CRP had increased to 98.4mg/L and the WCC decreased to 4.6 x10E9/L. A urine microscopy, culture and sensitivity (MCS) was sent that yielded no growth. The patient was discharged and instructed to return if her symptoms did not improve.

Three days later she was admitted via the emergency centre at another Health Care Facility. The patient presented with a severe headache, tenderness over the abdomen and nausea. Her temperature was 37⁰C and heart rate 136 beats/min. On examination the patient was jaundiced, mildly dehydrated and had diffuse tenderness over the abdomen, especially on the right side. The respiratory system was clear. A urine analysis indicated the presence of ketones, urobilinogen, bilirubin and blood. Laboratory results included a CRP of 196,6mg/L, FBC (Hb - 10.8g/dL, WCC - 7.4 x10E9/L and Platelet count – 10 x10E9/L) and LFTs (ALP – 34 IU/L, Protein – 59 g/L, Globulin – 25 g/L, Total Bilirubin – 186 umol/L, GGT – 368 IU/L, Alanine aminotransferase – 109 IU/L and Aspartate transaminase – 106 IU/L). The patient was admitted to the Intensive Care Unit. A malaria screen was done that tested positive. The patient tested positive for the Plasmodium falciparum and Pan-malaria antigen. After the diagnosis of malaria was confirmed, the patient recalled that she had recently (±16 days prior to becoming ill) sustained a needle stick injury. She had accidently pricked herself with the used stylet after commencing intravenous therapy for a patient that was admitted with Malaria. The index patient tested positive for the Plasmodium falciparum and Pan-malaria antigen with a parasite count of 3.7%. The staff member did not report the needle stick injury at the time of the incident. The patient was treated with Artemether-lumefantrine (Coartem®) over a period of 3 days and discharged after 6 days in hospital.


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