The 41-year-old relaxed his car at a location in front of a drugstore chain on the northern edge of Albuquerque. He was feeling unwell. Suddenly. , he began to shiver, then to shake. He watched helplessly as her arms, legs, whole 6-foot-5 body jump and shake like a rag doll shaken by a child. When the chills stopped, the seeThe air conditioning was suddenly as hot as the desert air outside. Nausea overcame him and he opened the door just in time to throw up whatever little he had eaten.
He had been feeling bad for days . Earlier that week, he took his wife for a walk in the beautiful mountain town of Durango, Colorado, where they lived. It was a walk they did all the time, but that day it felt heavy, like he was carrying a backpack. Just putting your feet up was an effort. Before leaving town, he took a quick Covid test - just in case. It was negative. Then he traveled to Albuquerque to participate in a long-awaited golf tournament. On the day of the competition his whole body ached, but he loaded up on acetaminophen and ibuprofen and made his way through all 36 holes. He felt too sick and too tired to attempt the four hour journeyes to go home that afternoon. He did another Covid test - he was negative again - then checked into a hotel to sleep.
It was a horrible night . The fever and chills culminated in sweats that soaked twice through his T-shirt. He finally fell asleep, waking up just before leaving to go home. Entering the highway, he had doubts. The road between Albuquerque and Durango was isolated. There were few gas stations and no cell service for much of the trip. He pulled into the pharmacy parking lot to think about his options, and that's when the chills set in. No doubt about it, he was ill.
He went to the nearest emergency care center. They confirmed that he had a fever, but since there was no laboratory on site, they could not tell him about it.much more. He found a hotel nearby and hoped for a better night. He didn 't have any. As soon as it got light outside, he went to the emergency room at the University of New Mexico hospital.
In the meantime, the man took his temperature with a thermometer he had taken from home him. It was 103. But by the time he was seen, a few hours later, it was back to normal. He felt sick but couldn't really tell what was hurting. He was given IV fluids which helped. The nurse told her he probably had some kind of virus, and she suspected he would be released once the labs were recovered.
Instead, blood tests showed her platelet count was dangerously low. Platelets are the blood cells that initiate the formationclots. Normally we have 150,000 to 400,000 platelets per microliter of blood. There were only 41,000. The emergency room doctor reassured him that the risk of spontaneous bleeding was not great as long as there were no less than 20,000 platelets. . More concerning, he told the patient, was his high level of bilirubin, a breakdown product of red blood cells. Something was destroying his blood. He was admitted to the hospital.
The next morning, Dr. Suman Pal, the hospitalist assigned to his care, went to see him. the most recent patient. Just looking at him, he could see that he was normally healthy but was quite sick now. He had jaundice - his skin and eyes had turned yellow from the increased bilirubin levels. And he moved relentlessly in the bed, as if he couldn't find a comfortable place. He had a fever during the night,but otherwise the only new finding was a mild rash due to her low platelet count. That number had dropped to 20,000, and his bilirubin had nearly doubled.
When the patient heard that his platelets had dropped to the level they had been given Said would put him at risk for bleeding, he called his wife. He had told her not to come to Albuquerque because it was probably "just a virus ", but now he was worried. I'm not going to die in this hospital, he told her over the phone. She immediately headed for Albuquerque. Image Credit ... Photo illustration by Ina Jang
Pal isreturned in the afternoon to tell the couple that the blood smear, ordered to find out what was destroying their red blood cells, had shown the presence of many tiny ring-shaped org anisms inside these cells . There were two possibilities: babesia - a tick-borne parasite seen primarily in the northeast and upper Midwestern United States - or malaria, a mosquito-borne infection that is common in much of the world but not here in this country. Had he traveled outside of the United States? Yes, he had been to London and parts of Scotland a few weeks earlier to visit his family. And soon after, he and his wife went hiking in Montana. Malaria is not common in any of these places. And although babesia has never been reported in Colorado, and only once in the past five years in Montana, it certainly hadbeen observed in other states of the United States. Babesia microti is a parasite that, like malaria, invades red blood cells to reproduce. It then bursts the cell to release a new generation of invaders, which then hijack even more cells. Infection with this parasite often causes high fevers, low platelet count and high bilirubin levels. Given his travel history, Pal told the couple this was the most likely diagnosis. They would start treating him for babesiosis with the two antibiotics recommended by the CDC
When his wife returned the next morning, the patient seemed even sicker. He was yellower and now had trouble finding the right word. This embarrassed him and worried his nurse, Getachew Gobena, who had spent 15 years treating malaria patients in different parts of Afrique as well as his native Ethiopia.
Gobena feared that it was not babesiosis at all. The ring shapes seen in the lab here were exactly like the ones he had seen in patients with malaria. In his experience, the diagnosis of malaria was often based on symptoms alone - and this man had those symptoms. His confusion was particularly disturbing.
Give the treasure time to work, the doctors urged the patient's wife. But when he didn't recognize her that afternoon, she felt a hint of terror. He wasn 't any better. As unlikely as the doctors said, could it be malaria after all?
Press an unlikely diagnosis
Gobena did not need any persuasion. Seeing the patient deteriorate, he was determined to take his case to the infectious disease specialist whenever he got the chance. Walking past the patient's room later that day, he heard the voice of Dr Mark Lacy, the infectious disease doctor who was covering this weekend. He showed Lacy pictures of the rings seen in the blood smear and expressed his concerns. Lacy had spent several years working in Indonesia, where he saw a lot of malaria. He agreed: The pictures were worrying for malaria. He walked over to the lab to look at the slides himself. As unlikely as it was, Lacy was certain the patient had malaria.
Hearing this, Gobena made a point of giving the patient the first dose of his antimalarial medication before he got home that evening. He had seen how quickly patients can deteriorate, especially when iThey get confused.
The next morning the patient's wife was amazed at how much better he looked. She walked over to her bed and asked the question she hoped he could answer: "Do you know who I am?" He paused for a moment.
"Of course, " he replied. "You are my beautiful wife. " Tears were streaming down her face. She recognized him too. He was back.
The results of the genetic test for the bug came back a few days later. It was malaria - and the deadliest version of this disease. By the end of the week, he was well enough to go home. Full recovery, however, took weeks longer. There are 2,000 cases of malaria in the United States each year. Almost all occur in people returning from areas where malaria is common. But there are cases when the source of infectionremains a mystery. In the literature it is known as airport malaria because in the first published cases transmission was linked to airports where flights to endemic areas were common. Was he infected at an airport? We'll never know. The only thing we can say for sure is that improbable does not mean impossible.
Lisa Sanders, MD, is a contributing writer for the magazine. His latest book is “Diagnosis: Solving the Most Baffling Medical Mysteries”. If you have a resolved case to share, write to [email protected]