Cynthia C. is a 19-year-old Kenyan female who came into our
outpatient clinic about 5 days prior to admission, complaining of feeling
dizzy, with nausea, headaches, and chills. Her exam at that time was fairly
unremarkable and she had some blood work done which was also within acceptable
limits. Her white blood cell count was checked and was low -normal, her
hemoglobin was slightly low (not unusual for a healthy young female), and her
platelet count was normal. She was sent home with the equivalent of Tylenol to
take as needed and was told to return should she begin to feel worse. On
1/14/24 she came back into casualty (the equivalent of our “emergency room”)
with recurrent headaches, subjective fever and chills, body aches, fatigue,
nausea, and some upper abdominal discomfort. Her lab tests were again drawn and
over the five day interval since being seen in the outpatient clinic, she had
developed an acute injury to her kidneys with declining function, a low normal
white blood cell count (arguing against a severe bacterial infection), a
worsening anemia, though still relatively mild, and a severe drop in her
platelet count from 150, 000 to 20,000 (with platelet counts of 10,000 or lower
one worries about the risk of spontaneous hemorrhages). She did not look particularly ill or unstable
at that time, but given the rapid decline in her platelets, and the associated
decline in white blood cells, and red blood cells, we were worried about the
possibility of some sort of bone marrow failure of production. We made the
decision to send her to a local teaching hospital about 2 hours away, where she
would have access to hematology and oncology services and the opportunity for a
more rapid evaluation of her bone marrow. Before the transfer could be arranged,
she spiked a fever to 39 degrees Celsius (or 102.2 degrees Fahrenheit). She
began to have shaking chills, lethargy, and confusion, dropping blood pressure,
difficulty breathing, and a rapid heart rate. She required initiation of
medication and fluids to support her blood pressure, oxygen to supplement her
breathing, and rapid re-evaluation to try to assess what was happening to her. She
was literally threatening to die in front of us. My intern and resident
re-examined her and thought that she had developed some right upper abdominal
tenderness, but nothing else had changed. The decision was made to cover her
for the possibility of septic shock (a bacterial infection extending to the
blood stream), and also to check her for the possibility of malaria ( a
protozoal infection of the red blood cells, obtained when bitten by an infected
mosquito.) Malaria is not common in or
around Tenwek, because the elevation here is about 6800 feet, and it is too
cold at night for mosquitoes to survive. To test for malaria, a sample of blood
is taken, some of the blood is smeared
onto a glass slide, and the red blood cells are examined under the microscope
for the presence of protozoal organisms within the red blood cell. This was
done by the hospital laboratory and was reported as negative. Both the intern
and the resident physician remained suspicious of severe malaria because a few
cases had recently been seen in the Bomet area. Our patient had not travelled
out of the Bomet area, and specifically had not visited areas of Kenya known to
have a high incidence of malaria. They contacted me and asked permission to
initiate empiric therapy for malaria while repeating another blood smear for
microscopic examination. Having never seen a case of malaria in all of my
career as a physician, it seemed quite ironic to me that I should be called
upon to make that decision. Since the patient was deteriorating so rapidly, and
we did not yet know what was wrong with her, I agreed with their request to
initiate malaria therapy while pursuing re-evaluation. She was started on
therapy, her blood smear was repeated, and this time was reported as positive!
This disease is almost always fatal when severe and untreated (though most cases
are usually not “severe”). With treatment, the mortality drops to about 5-7%. While
this disease is almost never seen in the United States, in Kenya about four
million cases occur annually! I am so thankful to be working along side these
young Kenyan physicians here at Tenwek. This patient almost certainly would
have died without their tenacious pursuit of the correct diagnosis, and their
decision to treat for what they suspected, even though there was no firm
evidence to support it. As a result of their care, the patient has begun to
improve. She is now off blood pressure supporting medications, her fever is
down, her alertness is improving, and her blood cell count abnormalities have
not worsened further. Her kidney function is also beginning to improve. She
remains quite ill but looks like she should make a full recovery. Each night
when the team on- call takes over, the rest of the team prays over them. A
common request is that God grant them endurance, strength, wisdom, and good
decision making. I cannot help but think that God, “the great physician,” was
present with us on this particular night. Another day in Kenya…another disease
process I have never personally seen or treated. It is a very humbling
experience to work here…another example of how my “weakness” allows for God’s glory
to be more clearly manifest. (2 Corinthians 12:9-10).
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| Malaria Infected Red Blood Cells |
