FEVER (spoiler alert, it's not malaria)

Dr. Algranati presented a great case last week at noon report!

A middle-aged Nigerian-American female with history of malaria 4 years prior and recently diagnosed Fe-deficiency anemia 2/2 uterine fibroids presented with complaints of 8 months of relapsing fevers and unintentional weight loss. She was found to have severe anemia (hgb 5.3) and elevated inflammatory markers (ESR 75). A workup for infection vs. malignancy was started. Given the history of malaria, there was significant concern for relapse, though multiple blood smears were negative. She eventually underwent endometrial biopsy to evaluate for possible endometrial cancer, which revealed necrotic & inflammatory tissue without evidence of malignancy, consistent with infected uterine fibroids. She was treated with antibiotics and her fevers resolved. The anemia improved with transfusion and is expected to resolve after definitive management of the fibroids.

A few reminders on malaria species:

The life cycles of P. vivax and P. ovale include dormant stages in the liver that can reactivate and cause relapse months-years later, however relapse beyond 2-3 years is extremely rare.

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For this patient, the type of malaria matters! Looking it up on the CDC website, the most likely species in Nigeria would have been P. falciparum, which does not have a dormant phase in the liver, again making relapse unlikely in this case.  

Case Take Home Points:

Certain forms of malaria can relapse months-years later, however relapse beyond 2-3 years is very rare.

Recognize anchoring. While malaria was a consideration for this patient, it really didn’t fit the clinical picture.

References:

Baird JK. “Non-falciparum malaria: Plasmodium vivax, Plasmodium ovale, Plasmodium malariae." UpToDate. Sept 26 2019.