Monday, April 30, 2012

Fever? Malaria.

  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.

      In any event, it was a very instructive case with a happy ending. I saw the same engineer several weeks later, and he was feeling much better. He expressed how grateful he was to have been working in a hospital when it happened and eagerly showed me his newly purchased mefloquine. Smiling, I pulled out my big blue doxycycline pills and showed him. It was a very nice moment, only possible here: an American and a German, sharing our malaria prophylaxis with big grins on our faces.

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