A 41-year-old man drove the car to a location in front of a chain pharmacy on the northern tip of Albuquerque. It felt awful. Suddenly he began to tremble, then trembled. He watched helplessly as his arms, legs, whole body the size of 6 feet 5 inches jumped and cracked like a rag doll shaking a child. When the chills stopped, the air-conditioned car suddenly became as hot as the desert air outside. Nausea gripped him, and he opened the door just in time to snatch what he could eat.
He felt sick for a few days. Earlier this week he went with his wife for a walk around the beautiful mountain town of Durango, Colorado, where they lived. They walked all the time, but that day he felt heavy – as if he were in a backpack. Just lifting my legs was an effort. Before leaving town, he passed a rapid test on Covid – just in case. It was negative. He then traveled to Albuquerque to take part in the long-awaited golf tournament. On the day of the competition, his whole body ached, but he was loaded with acetaminophen and ibuprofen and made his way through the muscles through 36 holes. He felt too sick and too tired to try a four-hour drive home in the afternoon. He took another test for Covid – he was negative again – then checked into a hotel to sleep over.
It was a horrible night. The fever and chills ended with sweat that permeated his T-shirt twice. He finally fell asleep, waking up on the way out to return home. Going out on the highway, he thought. The road between Albuquerque and Durango was isolated. There were few gas stations, and a significant part of the cellular service route was not. He stopped in the parking lot at the drugstore to consider his options, and then the chills began.
He went to the nearest emergency center. They confirmed that he had a fever, but since there was no laboratory in the room, they could not tell him anything more. He found the nearest hotel and hoped for a better night. He got none. As soon as the street lights came on, he headed to the emergency room at the University of New Mexico Hospital.
While waiting, the man measured the temperature with a thermometer, which he brought with him from home. It was 103. But by the time he was seen, a few hours later, it was back to normal. He felt sick, but he couldn’t say it hurt. He was given IV fluids, which helped. The nurse told him he probably had some kind of virus and she suspected he would be discharged as soon as they returned the lab.
Instead, a blood test showed that his platelet count was dangerously low. Platelets are blood cells that initiate the formation of blood clots. Usually we have 150,000 to 400,000 platelets per microliter of blood. He had only 41 thousand. The ambulance doctor reassured him that the risk of spontaneous bleeding was not significant until there were less than 20,000 platelets. More concerned, he told the patient, was his high bilirubin, a product of red blood cell breakdown. Something was destroying his blood. He was hospitalized.
The next morning, Dr. Suman Pal, the hospital designated to help him, went to see his newest patient. Only by looking at him could he see that he was usually healthy, but now quite ill. He had jaundice – his skin and eyes turned yellow from the increase in bilirubin levels. And he moved restlessly in bed, as if he had not found a comfortable place. His temperature rose at night, but otherwise the only new finding was a mild rash that appeared due to his low platelet count. That number dropped to 20,000, and his bilirubin almost doubled.
When the patient heard that his platelets had dropped to a level that he was told put him at risk of bleeding, he called his wife. He told her not to come to Albuquerque because it was probably “just a virus,” but now he was worried. I will not die in this hospital, ”he told her over the phone. She immediately headed to Albuquerque.
In the afternoon, Pal returned to tell the couple that a blood smear, which he ordered to find out what was destroying his erythrocytes, showed the presence in these cells of many tiny ring-shaped organisms. There were two possibilities: the babesia-tick parasite, which is seen predominantly in the northeastern and upper Midwestern United States, —or malaria, a mosquito-borne infection common in much of the world but not here in this country. Did he travel outside the US? Yes, he had been to London and some parts of Scotland just a couple of weeks earlier to visit his family. And soon after, he and his wife went on a hike to Montana. Malaria is not common in any of these places. And although Colorado has never been reported to have babesia, and only once in the last five years in Montana, it has certainly been seen in other US states. He then opens a cell to release the new generation of invaders who are capturing even more cells. Infection with this parasite often causes fever, low platelet counts and high bilirubin levels. Given the travel history, Paul told the couple that this was the most likely diagnosis. They began treating him for babesiosis with two antibiotics recommended by the CDC
When the wife returned the next morning, the patient felt even worse. He was more yellow and now had trouble finding the right word. This embarrassed him and worried Nurse Getachev Goben, who for 15 years cared for malaria patients in various parts of Africa as well as in his native Ethiopia.
Gobena worried that it was not babesiosis at all. The ring shapes seen in the lab were the same as in patients with malaria. In his experience, the diagnosis of malaria was often based solely on symptoms – and this person had these symptoms. His confusion caused particular alarm.
Give the treatment time to work, the doctors urged the patient’s wife. But when he did not recognize her that day, she felt a sting of horror. He did not get better. As unlikely as doctors may say, could it still be malaria?
Pressure on an unlikely diagnosis
Goben did not need to be persuaded. When he watched the patient deteriorate, he was determined to seek help from an infectious disease specialist as soon as he had the opportunity. Passing the patient’s room later that day, he heard the voice of Dr. Mark Lacey, an infectious disease doctor, covering the weekend. He showed Lacey the photos of the rings seen in the blood smear, and shared his concerns. Lacey worked for several years in Indonesia, where he saw a lot of malaria. He agreed: the shots are alarming from malaria. He made his way to the lab to look at the slides himself. As unlikely as it was, Lacey was certain that the patient had contracted malaria.
Hearing this, Goben decided to give the patient the first dose of antimalarial drug before going home that night. He saw how quickly patients could get worse – especially if they got confused.
The next morning the patient’s wife was surprised to see how much better he looked. She walked over to his bed and asked a question she hoped he could answer, “Do you know who I am?” He paused for a moment.
“Of course,” he replied. “You’re my beautiful wife” Tears streamed down her face. She also recognized him. He returned.
The results of the genetic error test returned a few days later. It was malaria – and the deadliest version of the disease. By the end of the week he was healthy enough to return home. However, full recovery took a few more weeks. There are 2,000 cases of malaria in the United States each year. Almost everything occurs in people returning from areas where malaria is common. But there are times when the source of the infection remains a mystery. In the literature, this is known as airport malaria because in the first published cases the transmission was related to airports where flights to endemic regions were common. Was he infected at the airport? We will never know. The only thing we can say for sure is that the unlikely is not the same as the impossible.
Lisa Sanders, MD, is the author of the journal. Her latest book is “Diagnosis: Unraveling the Most Fuzzy Medical Secrets.” If you have a case resolved, email her at Lisa.Sandersmd@gmail.com.