Case: It’s not the flu!
Pregnant Woman With Fever, Headache, and Chills
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“This isn’t the flu. I just know something is wrong with the baby!”
Case: Angela is a 27-year-old black woman who presents to your office with a chief complaint of malaise, headache, nausea, vomiting, and chills for two days. She is six months pregnant with her first child and has just moved to the area with her husband, having relocated for his job.
Past medical history is negative for anything other than usual diseases of childhood and appendectomy at age 16. She denies any problems conceiving, and until now, has felt fine throughout her pregnancy. She reports no environmental allergies or allergies to medications. Review of systems negative except for a history of eczema since childhood. She is very nervous that ‘something is wrong with my baby.’
Social history: She has worked as a school teacher but is at home full-time now. She returned three days ago from a one-month trip to rural Nigeria, where she was helping out with a family emergency. On further questioning, the patient mentions that she lived in Western Africa until she was 14, and has lived in the United States since then.
Medications: prenatal vitamins with calcium, iron, folic acid; topical corticosteroids as required to treat eczema flares.
She walks 1 to 2 miles every day and follows the prenatal diet she was given by her former OB-GYN.
Physical examination: Temperature 103.3ºF. She complains of a headache that has lasted for 2 days, as well as chills and vomiting. Skin: Some redness, crusting, and swelling over the hands, knees, and feet.
How would you proceed?
Published on March 1, 2011
Updated on March 8, 2011
Discussion
Angela has just returned from Nigeria, where malaria is rampant[1] (See Box). Malaria kills more than 300,000 Nigerians every year, which represents almost one-third of all malaria deaths worldwide. Among outpatient visits in Nigeria, 60% are malaria-related, and 30% of hospital visits are also related to malaria.[1]
Malaria is an acute febrile illness caused by any one of four Plasmodium parasites transmitted by the bite of Anopheles mosquitoes. Plasmodium falciparum and Plasmodium vivax are the most common; Plasmodium falciparum is the most deadly. Pregnancy reduces a woman’s immunity to malaria, making her more susceptible to infection. For the unborn child, maternal malaria increases the risk of spontaneous abortion, stillbirth, premature delivery, and low birth weight.[2]
Symptoms appear as early as seven days but typically 10 to 15 days after the infective mosquito bite. The first symptoms of fever, headache, chills, and vomiting may be mild and difficult to recognize as malaria.[3] Although Angela spent her early years in a region with a high incidence of malaria, she likely has lost much of her immunity to the disease. Therefore, she is at high risk whenever she returns to an area where malaria is endemic.[3]
About 1500 people are diagnosed with malaria in the United States each year, most of whom have traveled to parts of the world where malaria transmission occurs[4,5] (See Box). Because of her symptoms, her pregnancy, and her recent exposure to a malaria-endemic area, there is a high suspicion that Angela has malaria.
She was referred to an infectious disease specialist, who ordered a blood smear that confirmed the presence of P. falciparum. Because her symptoms indicated a very early stage of the disease that had likely originated in Nigeria, she was diagnosed with uncomplicated, chloroquine-resistant malaria.
She was started on the treatment regimen recommended by the CDC for pregnant women: quinine sulfate 542 mg base orally three times per day for three days (or a 324 dose capsule two times per day for three days) and clindamycin 20 mg/kg/day orally in three divided doses for seven days.[6]* She was sent home with instructions to complete both medications, to call immediately if the symptoms continued or the pregnancy appeared to be at risk, and to return in seven days.
Angela returned in seven days with complete resolution of all symptoms. She felt well and was instructed at that time about recommended malaria prophylaxis when visiting Africa and provided with contact information for the local hospital travel clinic.
*CDC recommends that for pregnant women diagnosed with uncomplicated malaria caused by chloroquine-resistant P. falciparum, treatment with doxycycline or tetracycline is generally not indicated. However, either drug may be used in combination with quinine sulfate if other treatment options are not available or are not tolerated, and the benefit is judged to outweigh the risks.
References
- Malaria prevention program in Nigeria aims at universal bed net coverage. The World Bank Web site. http://go.worldbank.org/LHEY74N9O0. May 2009. Accessed February 7, 2011.
- Lives at risk: malaria in Pregnancy. World Health Organization Web site. http://www.who.int/features/2003/04b/en/. April 25, 2003. Accessed February 7, 2011.
- Malaria fact sheet, April 2010. World Health Organization Web site. http://www.who.int/mediacentre/factsheets/fs094/en. Accessed February 7, 2011.
- Malaria and travelers. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/malaria/travelers/index.html. Updated February 8, 2010. Accessed February 7, 2011.
- Frequently asked questions: The disease: what is malaria? Centers for Disease Control and Prevention Web site. http://www.cdc.gov/malaria/about/faqs.html. Updated February 8, 2010. Accessed February 7, 2011.
- Centers for Disease Control and Prevention. Guidelines for treatment of malaria in the United States. May 18, 2009. http://www.cdc.gov/malaria/pdf/treatmenttable.pdf.
First, rule out malaria. Do lab work for malaria infection and anemia. Did she take any medication to prevent malaria while in Nigeria? Does the fever have a pattern. Is her liver and or spleen tender? Is dengue fever common in the areas she traveled to? ….