Friday, November 06, 2009

A Second Chance To Get It Right

This happened in Muscat, in 'Oman.

He was a student in the university. He had just returned from his native village to the campus after a vacation.
He was referred urgently because he had developed jaundice.

He told me he had felt hot and unwell for maybe 10 days. He had diarrhoea, not severe. He had rather vague abdominal discomfort.
He had noticed his eyes were yellow the previous evening; today he was worse.
Unexpectedly he said he had continued to eat, and smoke cigarettes.
There was no significant past history. He had taken no drugs.

Examination showed a well-nourished young man, obviously jaundiced, with a low fever, 38.4 degrees.
The liver was a little enlarged and tender; the spleen could just be felt.

This looked like acute hepatitis, most likely acute hepatitis B. His continued appetite for tobacco was puzzling; aversion to smoking is an important sign in hepatitis. Also I expected him to be more unwell with hepatitis, perhaps with a story of feeling better as the jaundice came out.
Still, everything else fitted.

I arranged some blood tests, and he was admitted to the ward.

Next morning I came to do a ward round, accompanied by a junior doctor and several students.
There was a commotion around a bed at the end of the ward. Several nurses were there, and another was hurrying up the ward carrying several hospital blankets.
It was my 'hepatitis' patient. He was shivering violently, shaking the bed, complaining of feeling cold.
This was a rigor, a sudden severe fever. His body temperature was rising rapidly. He felt cold because the body's thermostat had reset to a value hotter than normal, and had activated the mechanisms to increase heat production.
The clinical thermometer read 40.4 degrees. The penny dropped.

Hepatitis does not cause rigors. Acute malaria does - and malaria can occasionally present with jaundice. After all, the parasites destroy red blood cells, liberating haemoglobin, which is broken done in the spleen to produce the yellow pigment of jaundice, bilirubin.

I took another blood sample to the lab. My colleague quickly made the stained smear, and we looked using the oil-immersion microscope objective.
There they were: tiny parasites of Plasmodium falciparum in 1% of red cells.
Acute falciparum malaria.
An important experience for the students - and indeed, for their teacher.

Back to the ward, to prescribe quinine tablets, 600 mg. 8-hourly for 1 week.
The response was dramatic. His temperature was normal that afternoon; the jaundice disappeared in 2 days. He stayed in hospital until the treatment was finished - he could hardly go back to the student hostel where he had a room, and it was important to complete the treatment as prescribed.

Later I asked about his home village. It was in a wadi I knew well, with extensive palm groves and gardens attesting abundant water. Almost certainly it was a hot-spot for malaria.
"Where have you been recently" is a question to remember while taking a medical history.

No comments: