Influenza-like illness as an atypical presentation of falciparum malaria in a traveler from Africa.
BACKGROUND
According to the Centers for Disease Control and Prevention, the risk of fatal malaria in non-endemic countries can be reduced greatly if physicians are alert to the atypical presenting features of malaria.


METHODS
A patient arrived in the United States from Nigeria 2 days before presenting to an emergency department (ED) with sore throat, dry cough, fever (without chills), headache, and severe lethargy. A presumptive diagnosis of influenza-like illness was made. The patient improved after symptomatic treatment and was therefore discharged from the ED; she continued with her travel. After 24 h, the patient presented to our ED with symptoms suggestive of meningitis. The analysis of the cerebrospinal fluid was normal. A peripheral blood smear was diagnostic of falciparum malaria (parasitic index of 1). Because the disease was acquired from a chloroquine-resistant endemic area, the patient was treated with quinine and doxycycline, and she responded well.


CONCLUSIONS
In this era of heightened influenza alert, differentiating between influenza-like illness and malaria can be challenging. Patients with a history of travel to a malaria-endemic area in the preceding year should undergo a complete blood count (CBC), hepatic panel, and blood smear. Due to logistic reasons, the result of a blood smear may not be available immediately. Thrombocytopenia and hyperbilirubinemia each has a positive predictive value of 95% in the presumptive diagnosis of malaria. Patients who do not appear sick, and those who have a normal CBC and hepatic panel, may be treated symptomatically and discharged (with follow-up advised). Those with a presumptive diagnosis of malaria or unclear speciation should be admitted for anti-malarial therapy.
Sandhu
Gagangeet
G
Department of Internal Medicine, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York 10025, USA. gsandhu@chpnet.org
Ranade
Aditi
A
Ramsinghani
Prakash
P
Noel
Camille
C
D000328:Adult; D000962:Antimalarials / Q000627:therapeutic use; D003937:Diagnosis, Differential; D005260:Female; D005334:Fever / Q000209:etiology; D006801:Humans; D007251:Influenza, Human / Q000175:diagnosis; D016778:Malaria, Falciparum / Q000175:diagnosis* / Q000188:drug therapy; D010963:Plasmodium falciparum / Q000302:isolation & purification; D014195:Travel; D016896:Treatment Outcome
D000962:Antimalarials