Malaria in rural Lanarkshire

Jill Murie, Lorraine Urquhart

Jill Murie, GP.
Lorraine Urquhart, Practice Nurse

Kingshill Medical Practice
Forth
Lanark
ML11 8AJ

Correspondence to
Email jillmurie@aol.com/ jill.murie@nhs.net

Abstract
Introduction
Malaria is preventable, yet infection still occurs in UK travellers to tropical destinations. Effective health education, chemoprophylaxis and early identification of malaria are essential in primary care.
Case presentation
A 20 year old man presented with a fever associated with extreme lethargy and general myalgia during the H1N1 ‘pandemic’ in 2009. He was one of party of four people returning from The Gambia. Malaria was diagnosed and, following admission, Plasmodium falciparum parasites were identified. He was treated with intravenous quinine and doxycycline and made a full recovery. Two other members of the wedding party had flu like symptoms, but did not have malaria. One was diabetic.
Conclusion
Malaria must be considered in the differential diagnosis of fever in all people returning from the tropics. Primary care teams need to be aware of and encourage prevention strategies for people traveling to malarious areas. Diabetic patients may require dosage adjustments to prevent hypoglycaemia associated with anti-malarials.

Introduction
In the UK, it’s hard to imagine a place less exotic than ‘The Forth’, Lanarkshire. A remote and rural Scottish village 1000ft above sea level, Forth is the birthplace of ‘hot blast’, which revolutionised the early iron industry. Since the industrial decline of Lanarkshire, material deprivation prevents all but a minority of its community from travelling to tropical destinations. A stoical population with a high prevalence of co-morbidity, patients respond to bad news with an old adage attributed to a miner, ‘If it’s no clegs, it’s midges’ (‘Folk have always something to contend against’).1
This case report describes the return of a Forth wedding party from The Gambia accompanied by an unwelcome visitor at the height of the 2009 ‘Swine flu pandemic’ in November of 2009.

Case history
The four, a mother, son and his two friends left for a week in The Gambia apparently adequately immunised, advised and prescribed anti-malarial prophylaxis. The mother, a type 2 diabetic, was prescribed Lariam (Mefloquine) starting 2 ½ weeks before entering the endemic area and continuing 4 weeks after leaving. Her son was prescribed Malarone (proguanil hydrochloride 100mg, atovaquone 250mg) daily from 2 days prior to departure to 1 week following return from The Gambia.2

Five days after coming home the son, aged 20, presented to the practice nurse with a 7 day history of flu-like illness associated with extreme lethargy, myalgia and fever. He was of heterosexual orientation, had no significant past medical history and was not on medication. He admitted that he had missed anti-malarials in the Gambia and, on remembering, had taken his mother’s instead. Although neither had a net nor a spray, he was aware of having had only one insect bite in the 7 day period.

The practice nurse immediately considered a diagnosis of malaria rather than ‘Swine flu’ and took blood for malarial parasites. The antigen test was weakly positive for Plasmodium falciparum malaria. Later the same day, he was reviewed by a GP with the results. He was afebrile, but diarrhoea, nausea and vomiting had developed. He was admitted, somewhat bemused, to the local Infectious Diseases Unit (IDU)

On arrival to hospital, he appeared well with a temperature of 36.4, pulse 64, blood pressure 130/64, respiratory rate 14/minute and oxygen saturation 100% on air. His heart sounds were normal, chest clear and abdomen soft, non tender and with no palpable hepatosplenomegaly.

Meanwhile back in The Forth, the diabetic mother of the affected case presented with flu-like symptoms. Malaria rather than ‘Swine flu’ was her main concern.

Differential diagnosis
At the time of presentation to the practice there were numerous cases of ‘malaria like’ nonspecific symptoms and febrile illnesses associated with viruses including seasonal flu and an expectation of an impending H1N1 flu pandemic outbreak. Tropical causes of non-malarial fever originating in Africa to consider were rickettsial diseases, amoebic liver abscess, dengue and enteric fever and Katayama syndrome. Less common are leptspirosis, trypanosomiasis and viral haemorrhagic fever.3 HIV should also be considered.

Management
On admission to IDU, the initial blood film was reviewed microscopically to confirm malaria and quantify the parasitaemia. Initially haematology and biochemistry were normal (Hb 16.5, platelets 108, white cell count 3.6, neutrophils 3.1) apart from an elevated ALT 58, bilirubin 30 and CRP 73. His chest x-ray and ECG were unremarkable.

Image 1 Day 1: One malarial parasite (MP)

The patient was commenced on intravenous Quinine without a loading dose. An explanation for this was not available. When he spiked a fever of 39.8C the morning after admission, the parasitaemia rose to 2.5% (Image 2). He then received a Quinine infusion (15mg/kg of quinine salt infused over 4hours every 8 hours).

Vomiting developed followed by jaundice and he required supplementary intravenous fluids. There were, however, no cerebral symptoms and he remained well saturated on air.

Image 2 Day 2: 2.5% MP

Over the course of the next 2 days his platelet fell to 58 and his white cell count to 2.9 while maintaining a Haemaglobin of 14.6gm. There was no coagulation defect.

Daily blood films demonstrated a gradual reduction in his parasite count until 4 days after admission, when the percentage was less than 1%. Once his nausea and vomiting settled, intravenous therapy was discontinued and oral therapy was commenced with Quinine 600mg three times daily with Doxycycline 200mg once daily for 7 days.

Image 3 Day 3: 1% MP double ring

 

Image 4 Day 5: less than 1% MP

 

Image 5 Day 7: No MP

 

The patient made a full recovery. His travelling companions all presented at various times with flu-like symptoms, but none was tested positive for malaria.

Discussion
Epidemiology
Increasing numbers of people travel to sub-Saharan Africa, where malaria is endemic. Malaria is the most common tropical disease imported to the UK, where it causes around 10 to 20 deaths each year.4 In 2008, there were 1370 UK cases of malaria, of which 37 (2.7%) were imported to Scotland. Of these 23 (62.2%) were associated with falciparum malaria and none resulted in fatalities.5 There is a particular risk to people visiting The Gambia, from which the European Network on Imported Infectious Diseases Surveillance reported clusters of Plasmodium falciparum malaria arriving in the UK, in 2008.6

Forth is not situated in the vicinity of an airport, where mosquitoes may be imported to the UK via aircraft. In fact, in 2008/09, only one case of malaria was reported to NHS Lanarkshire (Linda Rogerson, Department of Public Health, personal communication). This is considered an underestimate because of under-reporting (Dr Nick Kennedy, ID Consultant, NHS Lanarkshire, personal communication).

Recognition of malaria
The reporting of any fever affecting travellers to high risk areas should prompt a diagnostic test for malaria even if the classical symptoms of fever, chills and rigors are absent. The characteristic presentation of ‘Cold stage, Hot stage and Sweating stage’ is uncommon until the infection is established, which is normally after a week. Headaches, vomiting, delirium, anxiety and restlessness may accompany febrile paroxysms.

In vivax malaria, the typical pattern of fever recurs once every 48 hours (Benign Tertian malaria). In falciparum infection (Malignant tertian malaria), the paroxysms tend to be more frequent (Sub-tertian). The malarial parasite degrades intracellular proteins, principally haemoglobin, resulting in haemolysis of the infected red cell and jaundice.

Laboratory diagnosis
Rapid diagnostic tests which detect plasmodial antigens or enzymes are not as reliable as diagnosis by direct microscopic visualisation of parasites in a peripheral blood smear. However, the accuracy of diagnosis and level of parasitaemia is critically important. Although one negative blood smear makes a diagnosis of malaria unlikely, smears should be repeated every 6 to 12 hours for 48 hours if malaria is still suspected. Malaria cannot be excluded until 3 blood specimens have been examined by an experienced microscopist.

Management
‘Falciparum’ malaria can be rapidly progressive in unprotected individuals with no immunity and all cases must be admitted hospital for at least 24 hours. Quinine is poorly tolerated and is always supplemented with oral doxycycline.7 Early diagnosis and treatment of potentially fatal malaria in travellers normally results in full recovery.

Malaria and diabetes
In diabetic patients, as in the case of the affected patient’s mother, falciparum malaria can cause hypoglycemia and vigilence is required. Further, intravenous quinine, the treatment of choice for severe or complicated malaria, may cause severe hypoglycaemia by stimulating the pancreatic beta cells and may potentiate the effects of sulfonylureas. It is therefore suggested that blood glucose be monitored closely and that appropriate medication adjustments are made.

Prevention of malaria
Owing to increased travel there is growing emphasis on personal protection measures against malaria including increasing awareness of risk, strict adherence to anti-malarial chemoprophylaxis and steps to avoid bites such as nets and sprays.

Training resources
There are many online resources on malaria for travellers and health professionals.8 9 10

The patient perspective

How does it feel having malaria?
‘It’s weird, hard to explain. One minute I was fine. Then it was like I had a bad cold with aches and pains. I couldn’t sleep because I was freezing, but my body was hot and shaking.
Half way through the week, I turned yellow. I needed an injection to stop me vomiting up tablets. I can’t remember some bits but I do recollect asking daft football questions…how embarrassing.’

What was important about your care?
‘Being given an explanation of the blood tests and type of malaria. Staff were ‘always’ there and checked up on me every 1 to 2 hours.’ Bloods were taken 2/ 3 times/day.’

Conclusion
In this case, early diagnosis and treatment of malaria was possible because of an astute practice nurse, who at the time was swamped, not by mosquitoes, but by H1N1 pandemic and seasonal flu and immunisation programes. It has already been reported in the BMJ that an erroneous label of H1N1 can result in the delayed diagnosis of life threatening infections.11

‘The Forth’ and The Gambia may be worlds apart, the former home to the intensely irritating but harmless midge and the latter, the Anopheline mosquito and malaria, potentially fatal but preventable with adequate prophylaxis. The key lessons for primary care are:

Malaria may present with symptoms indistinguishable from flu
Cases of malaria are under-reported to Public Health
Antigen testing is less reliable than expert direct microscopy
All patients with malaria must be admitted to an IDU
Special care must be taken with diabetic patients
Key health messages regarding malaria are ignored or misunderstood.
Competing interests
None

Acknowledgements
Authors acknowledge Dr Claire McIntosh, Specialist Registrar, Infectious Diseases Unit, Monklands Hospital, Airdrie for inpatient information and Michael Hughes, Haematologist, Monklands Hospital, Airdrie for haematological images.