Case Studies: Recurrent Fever, Chills, and Malaise in A 53-Year-Old Man

case studies
case study [microbiology] Principal Laboratory Findings

T1
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Recurrent Fever, Chills, Test Patient’s “Normal”
Results Reference Range
and Malaise in a 53-Year-Old
Hematology
Man WBC count 1.9 4.0-11.0 x 103/µL
RBC count 3.2 4.2-5.9 x 106/µL
Elliot Carter, MD Hematocrit 31.7 38.2-50.3%
Department of Pathology, University of South Alabama Medical Hemoglobin 10.0 13.2-16.7 g/dL
Center, Mobile, AL MCV 85 82-96 fL
Platelet count 65 146-394 x 103/µL
DOI: 10.1309/2XNG6E1GWX7VGY2T Differential cell count:
Segmented neutrophils 61 40.0-80.0%
Band neutrophils 10 0.0-6.0%
Patient Lymphocytes 24 15.0-50.0%
53-year-old man who recently returned from a trip to India. Monocytes 3 2.0-11.0%
Eosinophils 2 1.0-7.0%
Chemistry
Chief Complaint ALT 192 30-65 U/L
Episodic fever, chills, and muscle pain. AST 178 15-37 U/L
Bilirubin, total 12.4 0.2-1.2 mg/dL
Urinalysis
Medical History Hemoglobin 2+ Negative
The patient described a 1 week history of recurrent fever,
chills, and malaise. He had also experienced episodic WBC, white blood cell; RBC, red blood cell; mean corpuscular volume; ALT, alanine
aminotransferase; AST, aspartate aminotransferase
headaches as well as intermittent epigastric pain.
Family History
Unremarkable. 5. What is the treatment and outcome of individuals with
this patient’s condition?
Drug History
None. Possible Answers:
1. Recurrent fever, chills, malaise, jaundice, and diaphore-
Physical Examination sis in any individual returning from an area where a vari-
The patient appeared to be in no acute distress but was ety of endemic diseases is prevalent is striking. In
sweating profusely. His temperature was 102.5°F. He ap- addition, this patient’s WBC count was decreased; he was
peared slightly jaundiced. No hepatosplenomegaly was anemic, with a reduced platelet count and a modest shift
identified. to the left; his total bilirubin and liver enzymes, ALT and
AST, were significantly increased; and he had hemoglo-
Principal Laboratory Findings binuria.
[T1]
92 2. Malaria is endemic in many parts of the world, and a
Questions: complete travel history is usually very helpful in estab-
1. What is (are) this patient’s most striking clinical and lishing the possibility of malarial infection. Geographi-
laboratory finding(s)? cally, Plasmodium spp. are found predominantly in the
2. Based on this patient’s travel history and clinical signs Indian subcontinent, Southeast Asia, Africa, and Central
and symptoms, which laboratory test(s) should be per- and South America. Cases seen in the United States,
formed to diagnose the cause of this patient’s illness? Canada, Australia, and Eastern Europe are usually related
3. What is this patient’s most likely diagnosis? to recent travel by the patient to one of these malaria-en-
4. What are the characteristic clinical and laboratory fea- demic regions. Therefore, preparation and analysis of thin
tures associated with this patient’s disease? and thick peripheral blood smears for malarial parasites is
strongly indicated in this patient. The blood smears pre- also develop arthralgias, nausea, vomiting, abdominal
pared from this patient’s blood are shown in I1. pain, and hepatosplenomegaly. Although not commonly
present, liver abnormalities secondary to Plasmodium spp.
3. Most likely diagnosis: malarial infection with infection may occur. In addition, hepatosplenomegaly,
Plasmodium falciparum. jaundice, and hyperbilirubinemia occur in some cases of
Based upon the identification of the protozoan forms malaria, while liver function tests (ALT and AST) may be
seen on this patient’s peripheral blood smear, the diagno- variably elevated. Although not commonly present, liver
sis of Plasmodium falciparum malaria was made. More- abnormalities secondary to Plasmodium spp. infection
over, the patient’s symptoms of intermittent relapsing may occur. Lastly, like many blood-borne infectious dis-
fever and chills are consistent with this diagnosis. Four eases, malaria can cause significant hematologic/coagulo-
different species of Plasmodium may cause disease in hu- pathic sequela. One of these is disseminated intravascular
mans, and the identification of a specific species coagulation (DIC). Disseminated intravascular coagulation
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frequently relies upon correlation of the patient’s sympto- is one of the microangiopathic hemolytic anemias and
matology as well as morphologic characterization of the causes erythrocyte destruction in the microvasculature. In
Plasmodium spp. in the clinical laboratory. Two of the patients with DIC, abnormal coagulation studies as well as
Plasmodium spp., Plasmodium ovale and Plasmodium anemia and thrombocytopenia are seen. Hemoglobinuria
vivax, cause enlargement of erythrocytes and are associ- may be seen as a result of hematuria and erythrocyte lysis.
ated with Schuffner’s dots (coarse red granules) in the
erythrocyte cytoplasm. Plasmodium malariae and Plas- 5. Chloroquine is the standard therapy for prophylaxis
modium falciparum do not cause enlargement of erythro- against, as well as treatment of, malarial infections.
cytes and are not associated with Schuffner’s dots. These Chloroquine-resistant strains of Plasmodium falciparum,
2 species can usually be distinguished by the presence of however, exist in many areas of the world, and in these
banana-shaped gametocytes (seen only in P. falciparum) areas, patients may need to be treated with any of a vari-
in peripheral blood smears, as well as the relative percent- ety of second-line drugs, including quinine and
ages of erythrocytes involved (>10% for P. falciparum; quinidine. The outcome of a malarial infection depends
<0.5% for P. malariae). I1A and I1B show erythrocytes on many factors including the type of Plasmodium spp.
with readily apparent ring forms. The relatively uniform involved and the underlying health of the patient. Most
size of the erythrocytes, the absence of Schuffner’s dots, cases of malaria respond very well to treatment, but
and the percentage of involved erythrocytes suggest P. fal- chloroquine-resistant malarial strains may require the use
ciparum infection. It is the banana-shaped gametocyte of drugs which are not without toxic side-effects.
seen in I1B which is diagnostic of P. falciparum. Untreated cases of malaria may be fatal but may also
subside completely over time. Relapses of malaria may
4. Intermittent epigastric pain and relapsing fever, chills, occur years after infection with Plasmodium vivax and
diaphoresis, and muscle aches can occur in patients with Plasmodium ovale due to a dormant hepatic form of the
malarial infection. Infrequently, patients with malaria may parasite (hypnozoite).
A B
93
[I1] Patient’s peripheral blood smear demonstrating A) multiple erythrocytes containing intraerythrocytic malarial ring forms and B)
intraerythrocytic malarial ring forms and a banana-shaped gametocyte (arrow).

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case study [microbiology] Principal Laboratory Findings

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