Malaria Man

ID consults this month. The other day my fellow threw me a new patient- "middle aged HIV+ guy in the Obs unit with 5 days of fever and malaise: go check it out." Needless to say the differential diagnosis for this guy could stretch from here to the Indian subcontinent. I scouted out his records, checking his last CD4 counts and viral loads. Lingering in a healthy range and undetectable, respectively. I reviewed his admit and ED notes- some nausea (an equally nonspecific symptom), fever of 104, maybe a day of upset stomach. Nothing to grasp onto too tightly.

Then the story got strange. This guy was an academic, and as such he had traveled in recent years to Thailand, Myanmar (or Burma depending on your political persuasion) and remote regions of the aforementioned Indian subcontinent. He was a bit of an eccentric guy (I already told you he's an academic, right?) and had apparently eaten some pickled chinese mustard root and pork pot stickers earlier in the weak. What in the name of Buddha is pickled chinese mustard root, you ask? I have no idea, and apparently neither do the medical databases I searched in my over the top efforts to piece this dude together.

Then I stumbled on it: eosinophilia. The guy had two CBCs showing eosinophils in the 26-28% range, grossly elevated (should be around 3-5% or so).  Eosinophilia occurs in a few different scenarios, specifically:
1. Helminth infections (worms for the lay folk out there- we're talking blood flukes, hookworms, roundworms, etc.)
2. Fungal infections (your basic aspergillosis, coccidiomycosis, histoplasmosis, etc.- these can get real nasty, especially in an immunocompromised HIV+ guy).
3. Allergic reactions- (nuff said).
4. Eosinophilia syndromes (these are some oddball conglomerations of symptoms that constitute things like the infamous Churgg-Strauss syndrome)

The fact that his eosinophils were so elevated gave me something to work with- it allowed me to narrow my differential and cater my interview to specific risk factors and exposures (like caves and bat guano for histoplasmosis, for example).  But wait! What's that there? Another CBC? A CBC WITHOUT eosinophilia (2%)? Why are there two auto differentials showing elevations and one manual diff showing normal levels????

I phoned up the hematology lab, inquiring about the discrepancy. No explanation. The slides had been reviewed and the counts confirmed, but it made no sense. The nice lab tech on the phone offered to review the slides personally. Perfect. I marched off to the obs unit to interview the guy.

Halfway through the interview I get a call from the lab.
Lab: Is there anyway this guy could have malaria?
Me: Uhhhhh......yeah, actually, there is.
Lab: Good, because he has malaria.

Plasmodium vivax had been lying dormant in his liver for at least 9 months. He had no idea. The lab had missed it completely on three different CBCs that they allegedly reviewed. Had I not called about the eosinophilia discrepancy he would have likely remained undiagnosed for a long long time. As it is, he'll take some chloroquine for 3 days and primaquine for 2 weeks. That's it.

Malaria. Best day of med school yet.