A 57-year-old man with a 6-day headache and fatigue

Abstract

57-year-old man without notable past medical history resented to Johns Hopkins Hospital with a 6-day history of eadache and worsening fatigue shortly after returning from trip to Nigeria. During his time in Nigeria, he took pyimethamine for malaria prophylaxis. In the week leading p to his presentation, the patient also noted a cough, diarhea, and several presyncopal events, one of which caused im to lose his balance and strike his head. Four days prior o admission, the patient noted a subjective fever, severe hills, and dark brown urine. Throughout the course of his rehospital illness, he denied arthralgias, myalgias, nausea, omiting, diaphoresis, or abdominal pain. Physical examination revealed a slightly overweight man hose mental status deteriorated rapidly after his arrival in he emergency department. On initial presentation, he was oted to be both tachycardic at 112 beats per minute and achypneic at 25 respirations per minute. Oxygen saturation as 94% on room air. His HEENT examination was rearkable for icteric sclera, the lungs were clear to ausculation, and his cardiovascular examination was notable only or tachycardia. His abdomen was nontender, with a liver dge detected immediately inferior to the costal margin. here was no evidence of either splenomegaly or the stigata associated with cirrhosis. He was stuporous but had no ocal neurologic abnormalities. Laboratory studies revealed the following values: hematcrit, 28.0%; white blood cells, 3580/mm; platelets, 2,000/mm; serum potassium, 2.6 mEq/L; serum calcium, .9 Meq/L; total bilirubin, 4.7 mg/dL; lactate dehydrogease, 1382 IU/L; haptoglobin, 6 mg/dL; lactic acid, 3.8 mol/L; creatinine, 2.8 mg/dL; and glucose,115 mg/dL. A