The Brief Case: A 6-Year-Old with Fever, Abdominal Pain, and Recent Travel to Sierra Leone.

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A 6-year-old girl presented to the Nationwide Children’s Hospital emergency department in Columbus, OH, following a 3-day history of fever and 1 day of abdominal pain. She had recently returned from a 2-week trip to Sierra Leone and did not undergo any antimalarial prophylaxis. In the emergency department, she was found to be hypotensive and febrile and had altered mental status. Her maximum temperature from the day of admission was 40.1°C. She was started on broad-spectrum antibiotics, and laboratory testing was performed. Her initial laboratory results demonstrated a low hemoglobin of 8.9 g/liter, which dropped to 6.0 g/liter within 3 h (normal range, 11.5 to 15.5 g/liter), a total bilirubin elevated to 6.6 mg/dl (normal range, 0.1 to 1.0 mg/dl), and lactate dehydrogenase of 1,582 U/liter (normal range, 350 to 850 U/liter). These symptoms and lab findings prompted the clinical team to order a malaria evaluation, including thick and thin blood smears and an immunochromatographic malaria rapid diagnostic test (BinaxNOW Malaria; Abbott Laboratories, Abbott Park, IL). This assay detects the histidine-rich protein 2 (HRP2) antigen specific for Plasmodium falciparum on line T1, as well as a pan-malarial aldolase on line T2, which is expressed in all of the malaria species that infect humans: P. falciparum, P. vivax, P. ovale, and P. malariae (1). The screen for this patient generated T2 and control bands, indicating infection with P. vivax, P. ovale, or P. malariae (Fig. 1A). However, examination of peripheral blood smear showed morphologic findings consistent with P. falciparum species (frequent ring forms with more than one chromatin dot, multiple ring forms infecting the same red cell, and infected red cell size similar to noninfected red cells). Parasitemia was high, with more than 20% of red cells infected (Fig. 1B).