Case of the Month -June 2017
MISERY ACQUAINTS A MAN WITH STRANGE BEDFELLOWS
Ms Lee Baker, Amayeza Info Centre, President, SASTM
Albie de Frey, Travel Doctor Johannesburg, Executive Committee Member, SASTM
A 57-year-old previously healthy Caucasian South African man was medevaced to a private hospital in Johannesburg from Lubumbashi in the Democratic Republic of Congo in mid-December 2016.
He travelled to the DRC on 18 November 2016 where he had been working at a mine in Kakunda, Katanga for several months.
His home is in Sasolburg but he had been working as an expatriate for several years in Mozambique, Botswana, Mali, Ghana, Zambia, Burkina Faso, Liberia and Namibia. During the course of his expatriation he had been fully vaccinated against yellow fever, hepatitis A and B, typhoid, meningococcal disease, tetanus, polio, diphtheria and pertussis. He does not take malaria prophylaxis and does not keep any animals at home in a residential suburb in southern Gauteng.
He had documented malaria 3 years prior to this episode and was on methyl-dopa 500mg 8 hourly for hypertension. He smokes 20 per day for the last 20 years and drinks two units of alcohol per day.
On 6 December 2016, he presented to the mine clinic with severe headache, fatigue and myalgia. He was given Vitamin B1 and B6 injections and diclofenac per rectum…
The next day he developed a high fever, yellow diarrhoea and “black urine”. Malaria screening was apparently negative.
On the third day of illness he was referred to a private clinic in Lubumbashi where he was diagnosed with “2 +” Plasmodium falciparum malaria, put on an intravenous infusion, given azithromycin orally and received a series of artemether injections.
On Day 5 he was sent back to the mine as his malaria smear was now allegedly negative - he still had a severe, persistent headache and vomited on the evening of the fifth day. He was given Mypaid® (Ibuprofen / paracetamol) on the seventh day and with still no improvement on Day 8 he flew to Johannesburg on a commercial flight.
On examination he appeared generally well, was apyrexial with normal vital signs. He had no meningism, jaundice, clubbing, lymphadenopathy or pallor but a fine macular rash was noted on the all four limbs including the palms and soles. He had no eschars or other insect bites, no conjunctival congestion and the rest of the examination was unremarkable.
He had a normal chest X-ray and abdominal sonar, normal resting ECG and his urine was clear.
Laboratory screening was as follows:
Full Blood Count
|Haemoglobin||11.9||14.3 – 18.3||g/dl|
|Red Cell Count||4.06||4.89 – 6.11||10^12/l|
|Haematocrit||36.4||43 - 55||%|
|White Cell Count||8.92||3.92 – 9.88||10^9/l|
|Neutrophils||3.48||2 – 7.5||10^9/l|
|Lymphocytes||3.79||1 - 4||10^9/l|
|Monocytes Abs||1.25||0.18 – 1.00||10^9/l|
|Eosinophils||0.21||0 – 0.45||10^9/l|
|Basophils ||0.05||0 – 0.2||10^9/l|
Malaria thin smear, P falciparum Antigen, Common falciparum Antigen and QBC all negative
|Total Protein||68||60 - 83||g/l|
|Albumin||30||35 - 52||g/l|
|Globulin||20 - 35||g/l|
|ALP||40 - 130||U/l|
|Gamma GT||181||< 60|
|Bilirubin Total||5||5 - 21||umol/l|
|C-Reactive Protein||100||< 5||mg/l|
Salmonella and Rickettsia serology was negative. Dengue screening was negative but the Brucella IgM was considered positive with a value of 3,6 (Normal ration 0.0 – 0.7) Brucdlla IgG was negative.
On clinical grounds, in the face of the positive IgM, in the absence of laboratory evidence of any other infectious disease and in lieu of the seriousness of chronic brucellosis he was commenced on doxycycline and rifampicin for a month.
A month after his admission in Johannesburg the IgM, IgG and PCR for Brucellosis was repeated. It was all negative…
Question 1 - Did the patient have malaria?
Continue to Answer 1