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• W2086187859 abstract "The diagnosis of malaria can be missed when there is a significant time lag from exposure and negative initial tests. As clinicians we must always consider the diagnosis in the appropriate clinical setting as a missed diagnosis can potentially result in serious consequences.A 27-year-old Nigerian woman presented with a 2-day history of headaches, mild photophobia, sweats and fever. She arrived in the UK from Nigeria 8 months previously and had not been back since. On admission she was unwell with a temperature of 38.5°C, pulse 110/min but otherwise haemodynamically stable. Examination revealed a soft ejection systolic murmur and signs of meningism, but her neurological assessment was otherwise entirely normal. Her initial investigations showed a haemoglobin level of 11.8 g/dL, white cell count 3.9×109/L, lymphocytes 0.5×109/L, platelets 118×109/L, C-reactive protein 121 mg/L; urea and electrolytes and liver function tests were normal.She was commenced on ceftriaxone 2 g daily with a presumptive diagnosis of meningitis. The patient had a normal computerized tomograph of the head, which was followed by a normal lumbar puncture. Two sets of blood cultures and a mid-stream urine sample had no growth after 48 h. The initial admission pyrexic thick and thin blood film and malarial antigen test (Optimal, DiaMed) were negative.She improved initially with antibiotics and intravenous fluids. 24 h into her admission, having been reviewed by a number of senior doctors, her working diagnosis was changed to one of a viral illness and plans were made for her discharge. Malaria was felt to be unlikely given that not only was she 8 months post-exposure for malaria, her blood film and antigen test were negative.However, on the day of discharge she was found to spike a temperature of 38°C and remained thrombocytopenic (108×109/L). It was decided that in view of her country of origin and the fact that she remained thrombocytopenic, malaria still needed to be considered. Even though a thick and thin blood film and malarial antigen test (Optimal, DiaMed) were negative, we felt three negative blood films were needed before excluding malaria and labelling her as a patient with a viral illness.Interestingly, a repeat blood film showed malarial parasitaemia of 5% Plasmodium falciparum (Figure 1). Her haemoglobin dropped to 9 g/dL and platelets dropped to 93×109/L over the next 2 days, which then recovered. She was treated with intravenous quinine (10 mg/kg) for 48 h and converted to oral quinine for 7 days followed by three tablets of oral pyrimethamine with sulfadoxine (Fansidar). She was discharged home with a negative parasitaemia.Figure 1Patients blood film showing malarial parasites (in colour online)" @default.
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• W2086187859 date "2006-04-01" @default.
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• W2086187859 title "How easily malaria can be missed" @default.
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• W2086187859 doi "https://doi.org/10.1258/jrsm.99.4.201" @default.
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