In the
hospital, the term patients use to describe any fever is palu, a shortened version of the french term for malaria, paludisme. In fact, malaria is so common
here that patients assume any fever is malaria. So when a patient comes in and
says “Docteur, J’ai palu,” what they are really saying is “Dr, I have a fever.”
The
month before I got here, the hospital was hit with a malaria epidemic. Every
hospital bed was filled with malaria patients, and the hospital was
short-staffed because half of the nursing staff was also out with malaria. And
in fact, every week since I arrived, we have received at least 3 patients with
malaria. This steady stream of patients is due, in part, to the fact that February
to May in Gabon is the rainy season.
As a result all patients who arrive to the
urgences or ED all receive a CBC and
thick smear (the rapid test is too expensive). If the thick smear is positive,
the nurses automatically hang quinine and D5. It is routine and common.
Plasmodium falciparum is the predominant form in Central Africa and it is the
most virulent. Although most of our patients have very strait forward hospital
stay, we have the occasional severe case. Usually the most severe cases are
among people like me, foreigners who are “naïve” to plasmodium, or very young
children. There is a higher risk of fatal complications like cerebral malaria
in naïve hosts and children.
Mosquito netting, at home and on the wards.
My attending has treated countless
students and researchers for malaria. The worst case he has ever seen was the
case of a European student who developed a case of cerebral malaria. She had
been having fevers for four nights before she realized she was infected. After
three days on oral CoArtem (Artemeter derivative), she was rapidly
deteriorating. By the time he saw her, she was unresponsive and her parents
were boarding a flight to Gabon. He
stayed up all night with her and, despite the worldwide emphasis on Artemether
derived medications, he used the old standby, quinine. (For the medical folks
out there, he told me that in his experience the most successful way to treat
cerebral malaria is to use a huge loading dose of quinine, at least 4 times the
normal dose). By morning, she was awake and conscious enough to speak to her
parents.
A sign which I spotted in the terminal at Charles de Gaulle. I appreciated the reminder; the risk of developing malaria after returning is not insignificant.
My attending often shares anecdotes like
that one with me, and I have found that Gabon is a wonderful place to learn
about malaria. The hospital is home to a world-renowned research center, the Unite des recherches medicales,
affectionately called the URM. The URM is home to research about
tuberculosis, HIV, filarial diseases, but the main focus of the center is
malaria. Work is conducted by a collection of ex-patriots from African
countries (Senegal, Togo, Nigeria) and Europeans (Mostly German, some Swiss,
Spanish and French). The center is affiliated with the University of Turblingen
in Germany and many of the students come for six months to a year to work on
the projects.
The URM, one of two buildings dedicated to research in tropical medicine.
Some of the key research going on now is
concerned with maternal-child health. There are several vaccine trials for
children; the largest is a multicenter trial with sites in Senegal and the DRC.
The other regards the use of mefloquine as malaria prophylaxis for expectant
mothers. It is exciting work and I enjoy discussing malaria with world-renowned
malaria experts at the cafeteria every day.
A case I witnessed here taught me several
very important lessons about the management of malaria. A foreign engineer came
to hospital to assess the electrical infrastructure. Originally from Germany,
he had traveled widely throughout Central and West Africa and had never taken
any prophylaxis. Four days into his visit (after a week of heavy rains), he
came to the urgences, with his heart
racing, trembling hands and a fever of 103F. His thick smear was negative (and
read by the best technician in the lab).
I took several things away from this case, valuable lesions about
malaria treatment in endemic areas.
LESSON 1:
If the thick smear is negative but the clinical picture tells you it is
malaria (and you are in an endemic area): TREAT IT! Sounds simple, but I
learned it here. Everything about his presentation fit the textbook definition
of malaria and the thick smear, while useful and cheap, is not terribly
sensitive. In addition, in naïve patients,
a thick smear may show very few parasites when in fact the illness is severe
(in contrast to people from endemic areas who may be asymptomatic with a very
high parasite burden). As it turnes out, he took a rapid test when he got back
to Germany which was positive.
LESSON
2: If the thick smear is negative, look at the platelets. If the platelets are
low, this could suggest malaria. I don’t know that this would be clinically
acceptable in the States, but here there are several reasons the physicians
rely heavily on the platelets. First, the most common cause of thrombocytopenia
here is malaria. Secondly patients often come from villages far enough away
that the clinicians hesitate to send them home without some treatment. The fear
is that a patient with a negative thick smear could be sent home, become ill
and be unable to return. In practice it
is decision more supported by a public health perspective, taking into
consideration factors unique to this clinical setting.
LESSON 3: Hang quinine with D5 or D10, never
with NaCl. I learned this from one of the senior nurses. She saw me reach for
NaCl and violently pulled it out of my hands. She gave me a crazy look and said
“L’Americaine! Quinine needs sugar! Don’t they teach you that in the US?!” I
wanted to say “ Well NO, actually we learned which meds to use, the parasite
life cycle and kept going.” But I didn’t, and I will never forget the lesson.
Later on, I looked it up in my Oxford Manual and read that quinine is thought
to increase the risk of hypoglycemia, a risk which is already elevated by
having malaria itself.