He had suddenly become ill and was trembling violently. what was happening?
The 41-year-old eased into his car in front of a chain drugstore on the north shore of Albuquerque. He felt terrible. Suddenly he began to tremble, then trembled again. She watched helplessly as her arms, her legs, her entire 6-foot-5-inch body were jumping and moving like a rag doll moved by a child. When the trembling stopped, the air-conditioned car suddenly felt as warm as the desert air outside. Nausea struck, and he opened the door prematurely so that he could vomit a little of what he could eat.
He was feeling ill for several days. Earlier that week, he went with his wife to visit Durango, the beautiful mountain town of Colo, where they lived. It was a walk he used to take all the time, yet he felt a heaviness that day – as if he was wearing a backpack. Just raising his legs was an effort. Before leaving the city, he took a COVID rapid test – just in case. It was negative. Then he moved to Albuquerque to participate in the long-awaited golf tournament. On competition day, his whole body ached, but he filled himself with acetaminophen and ibuprofen and made his way through 36 holes. He felt too sick and too tired to attempt the four-hour drive home that afternoon. He took another COVID test – it was negative again – then checked himself into a hotel to sleep.
It was a terrible night. Fever and chills culminated in sweat that drenched his T-shirt twice. He finally fell asleep, woke up at checkout time to go home. Other thoughts came to his mind as soon as he entered the highway. The road between Albuquerque and Durango was isolated. There were few gas stations and no cell service for a good part of the way. He walked into the drugstore parking lot to consider his options, and that’s when the bone-rattling chills struck. No question about it, he was sick.
He went to the nearest urgent care center. They confirmed that he had a fever, but because there was no laboratory on the premises, they could not tell him more. He found a hotel nearby and looked forward to a better night. He didn’t get one. As soon as it was light outside, she headed to the ER at the University of New Mexico Hospital.
As he waited, the man took his temperature with a thermometer he brought with him from home. It was 103. But by the time he was seen hours later, everything was back to normal. He felt sick but couldn’t really say what hurt. He was given IV fluids, which helped. The nurse told him she probably had some kind of virus, and suspected that she would be discharged once she got back to the lab.
Instead, blood tests showed that his platelet count was dangerously low. Platelets are blood cells that initiate clotting. Normally we have 150,000 to 400,000 platelets per microliter of blood. They only had 41,000. The ER doctor reassured him that the risk of spontaneous bleeding was not significant until he had less than 20,000 platelets. More worrying, he told the patient, was his high level of bilirubin, a breakdown product of red blood cells. Something was destroying his blood. He was admitted to the hospital.
The next morning, Dr. Suman Pal went to see his newest patient, at the hospital assigned to his care. Upon seeing her, he could see that he was normally healthy but now very ill. He had jaundice – his skin and eyes turned yellow from rising levels of bilirubin. And he lay restless on the bed, as if he could not find a comfortable place. He had an overnight fever, but otherwise the only new finding was a mild rash coming from his low platelet count. That count had dropped to 20,000, and her bilirubin had nearly doubled.
When the patient heard that his platelets had dropped to a level he was told would put him at risk of bleeding, he called his wife. He was telling her not to come to Albuquerque because it was probably “just a virus,” but now he was worried. I’m not going to die in this hospital, he told her over the phone. She immediately moved to Albuquerque.
Pal came back in the afternoon and told the couple that blood smears ordered to find out what was destroying their red blood cells showed the presence of several small ring-shaped organisms inside those cells. There were two possibilities: babesia – a tick-borne parasite seen mainly in the Northeast and upper Midwest in the United States – or malaria, a mosquito-borne infection that is common in much of the world but not in this country. Did he travel outside the US? Yes, he had gone to London and parts of Scotland only a few weeks back to visit his family. And shortly after that he and his wife went hiking in Montana. Malaria is not common in any of those places. And while Babesia has never been reported in Colorado and only once in the past five years in Montana, it was certainly seen in other states in the U.S. Babesia microti is a parasite that, like malaria, is red for reproduction. attacks blood cells. It then bursts the cell open to free a new generation of invaders, which then hijack even more cells. Infection with this parasite often results in high fever, low platelet count and high levels of bilirubin. Given their travel history, Pal told the couple, this was the most likely diagnosis. They will begin treating her for babesiosis with two antibiotics recommended by the CDC.
When his wife returned the next morning, the patient seemed even more ill. He was paler and now he was having trouble finding the right words. This embarrassed him and worried his nurse, Getachev Gobena, who had spent 15 years caring for malaria patients in different parts of Africa as well as in his native Ethiopia.
Gobena was worried that it was not babysiosis at all. The ring forms seen in the lab here were similar to those seen in patients suffering from malaria. In his experience, the diagnosis of malaria was often based on symptoms alone – and this person had those symptoms. His confusion was particularly worrisome.
Give the treatment time to work, doctors urged the patient’s wife. But that afternoon when he did not recognize her, he felt a sense of fear. He was not getting well. As the doctors said that was unlikely, could it be malaria?
suppressing an unlikely diagnosis
Gobena needed no persuasion. As he watched the patient deteriorate, he was determined to report his case to an infectious disease specialist as soon as he got the chance. Walking through the patient’s room later that day, he heard the voice of Dr. Mark Lacey, the infectious disease doctor who covered that weekend. He showed Lacey pictures of the rings he saw in the blood smear and shared his concerns. Lacy had spent many years working in Indonesia, where he saw a lot of malaria. He agreed: the photos were worrisome for malaria. He himself went to the lab to see the slides. As it was unlikely, Lacy thought the patient had malaria.
Hearing this, Gobena told the patient to give the patient the first dose of his anti-malarial drug before going home that night. He had seen how quickly patients could deteriorate – especially once they became confused.
The next morning, the patient’s wife was amazed to see how much better he looked. She went up to his bed and asked the question she hoped he could answer: “Do you know who I am?” He paused for a moment.
“Of course,” he replied. “You are my beautiful wife.” Tears welled up from his face. He recognized her too. He was back.
The bug’s genetic test results came back a few days later. It was malaria – and the deadliest version of that disease. By the end of the week, he was well enough to go home. However, full recovery took weeks longer. There are 2,000 cases of malaria in the United States each year. Almost all occur in people returning from areas where malaria is common. But there are cases in which the source of infection remains a mystery. In the literature, it is referred to as airport malaria because transmission in the first published cases was linked to airports where flights to endemic areas were common. Was he infected in an airport? we will never know. The only thing we can say for sure is that impossible is not the same thing as impossible.
Lisa Sanders, MD, is a contributing writer for the magazine. His latest book is “Diagnosis: Solving the Most Baffling Medical Mysteries”. If you have a resolved case to share, write it to [email protected]
#suddenly #ill #trembling #violently #happening