SHM Converge Scientific Abstract ePoster Gallery-Fluctuating Levels of Parasitemia in a Case of Severe Malaria

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This case describes a woman with 5 days of intermittent fevers, headache, fatigue, and diaphoresis after living in remote South Sudan without malaria prophylaxis and recent international travel. On admission, she was febrile, tachycardic, and appeared acutely ill, with scleral icterus, right upper quadrant tenderness, and mild hepatomegaly.<br /><br />Initial workup showed hemolytic anemia and liver injury, including elevated LDH, very low haptoglobin, hyperbilirubinemia, and elevated lactate. A malaria antigen test was positive, and the first peripheral blood smear showed only 0.3% parasitemia. Because this level seemed low, clinicians initially considered bacterial co-infection or pulmonary embolism as alternative explanations. Imaging showed bilateral pleural effusions, but CT angiography was negative for PE.<br /><br />Her condition worsened, with dyspnea and oxygen requirement. A repeat smear 12 hours later revealed 35% parasitemia, confirming severe Plasmodium falciparum malaria. She was treated with intravenous artesunate every 12 hours for three doses. Her hemolysis resolved and symptoms improved. A final smear after treatment showed parasitemia down to 0.1%, and she was discharged on oral artemether-lumefantrine with infectious disease follow-up.<br /><br />The key teaching point is that malaria should be strongly suspected in any febrile patient with travel to or residence in an endemic area. Importantly, parasitemia can fluctuate markedly because infected red cells may sequester in tissues, so a low initial smear does not exclude severe malaria. Per CDC guidance, malaria can only be ruled out after three peripheral blood smears, each obtained 12–24 hours apart, are negative.

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Tahir H. Malik

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Author List Alexander Chee, Luke O'Donnell, Maria Aguero-Rosenfeld, Michael Shen, Nathan Lorentz, Oliver Stewart, Patricia Pagan Pirallo, Robert Mitrani, Tahir H. Malik, Vanessa Raabe, Vinh Pham

Category Clinical Vignettes

Concept Malaria

Concept Severe Malaria

Concept Intravenous artesunate

Concept Plasmodium falciparum

Concept Peripheral Blood Smear

Distinguished Non-Finalist

Presenter Organization New York University, Internal Medicine

Presenting Author Tahir H. Malik

Track Adult

Keywords

Plasmodium falciparum

severe malaria

parasitemia

intravenous artesunate

hemolytic anemia

travel to South Sudan

febrile illness

peripheral blood smear

malarial sequestration

artemether-lumefantrine

Malaria

Severe Malaria

Intravenous artesunate

Plasmodium falciparum

Peripheral Blood Smear