- Sierra Leone. A child weighing 20 kg suddenly develops fever. The mother decides to wait and see. The next day the general condition is poor and chloroquine is given. The day after the child is in a stupor and is brought to the local hospital. The child has a fever of 40°C. It is comatose. There is no neck stiffness. A thick smear is positive and a thin blood smear confirms parasitaemia with P. falciparum of 7 % (percentage of parasitised red blood cells). What do you do?
- Indonesia. A pregnant woman presents with P. vivax malaria. What do you do?
- Niger. A local man comes to ask your advice. He wants protection against malaria but cannot take chloroquine due to eye problems. What do you suggest?
- Laos. One of your colleagues develops fever every 3 days. A thin blood smear shows some trophozoites of P. malariae. Should Nivaquine and Primaquine be administered?
- Zambia. A mother brings you a very ill child: fever, tachypnoea. A thin blood smear shows some sparse gametocytes of P. falciparum. What do you do?
- North Angola. A man aged 40 comes to ask for your help. In recent months he has felt very weak, is easily tired after normal exertion and has pain under the left ribs. You palpate an enlarged spleen and you notice pale conjunctivae. There is no leishmaniasis in the region. Blood analysis shows haemoglobin at 5 g/dl. No malignant cells are seen. There is no lymphadenopathy. There is no ascites, no previous history of haematemesis, no signs of portal hypertension, also no spider naevi, gynaecomastia or polyneuropathy. The stools contain no eggs of schistosomes. What do you think and what do you do?
- A Belgian development assistant arrives in Central Africa. It is his first journey abroad. Three days later he develops fever to 40°C. He was taking Nivaquine and Paludrine and thinks that he cannot have malaria. What do you think?
- Malawi. A patient is admitted with falciparum malaria. He is treated with quinine IV and vibramycin PO. The fever drops but his general condition deteriorates. The blood pressure drops. He remains conscious, the urine production is 700 ml per 24 hours. On the fourth day he is very seriously ill. What would you do?
- Nicaragua. A woman is brought in with high fever. Her general condition is not so good. Your colleague thinks that it might be severe malaria and quickly injects an ampoule of Nivaquine® IV. The woman then loses consciousness and dies shortly afterwards. What has happened?
- Can people who are carriers of sickle cell anaemia get malaria?
- Central African Republic. When the supply of tetracycline has been used up, can you then use streptomycin in the treatment of malaria, while you wait for new supplies?
- A
Bolivian woman has lived all her life in the high mountains. One day she goes to the eastern, low-lying part of the country for 3 weeks. She takes mefloquine as prophylaxis. Five months after her return to the high mountains she develops fever. Can this be malaria? Explain your answer.
- Angola. A man, 50 kg, is admitted with coma and fever. There is no neck stiffness. A thin blood smear from peripheral blood shows parasitaemia of 2%
Plasmodium falciparum (all trophozoites). What do you do?
- Congo. A 50- year-old missionary develops malaria (P. falciparum). She takes 3 x 2 tablets of Quinimax per day for 3 days, yet on the 4th day there is still fever and there are still parasites in the peripheral blood. What do you think?
- Does a thick smear have high specificity or high sensitivity for the diagnosis "malaria"? Explain.
- Guinea.
The symptom "fever" is often equated with the disease "malaria". This sometimes happens without a search for focal signs (pain upon percussion over a kidney, tachypnoea-dyspnoea, neck stiffness, etc.). For this reason chloroquine is often given indiscriminately. Give a number of arguments for and against this approach. Your answer should include frequency of infection, chronic carriers, toxicity and cost price of drugs, resistance, missing other diagnoses, frequency and importance of other diagnoses, cost price and time to obtain microscopic diagnosis, the reliability of this diagnosis, lack of motivation, poor information and training of local staff.
- Peru. A man has never been in a malaria zone. He is admitted with fever and a thick smear is positive for Plasmodium. Could the fact that a few weeks ago he underwent a bloody operation, be of importance? Are there other possible explanations? If this proves to be P. vivax, should primaquine be given?
- Gabon. A man is suffering from neck pain and takes an Artenam® tablet. The discomfort disappears. It is usual in the area to regard such discomfort as "mini malaria". What effect might this human behaviour have on the development of resistance of malaria parasites to this drug?
- Thailand. A German woman travels to the border with Myanmar for several days to visit the hill tribes. She stays overnight in the jungle. As malaria prevention she takes mefloquine, 250 mg per week. Two weeks after her journey she is admitted in Bangkok with confusion, hallucinations and psychotic behaviour. The physical examination is normal. She is afebrile and the glycaemia, the ionogram and the blood count are normal. The thick smear is negative. Are there probable alternative diagnoses apart from mental decompensation due to culture shock?
- The above-mentioned woman gives birth 6 months after her return to Europe. The baby develops massive haemolysis a few weeks after birth. The diagnosis is congenital P. vivax malaria. Do you require extra information and what treatment do you administer? Other remarks?
- Tanzania. A married couple travel to various wild parks. The man takes mefloquine as prevention, but the woman takes nothing against malaria. On the tenth day they both develop nausea, watery diarrhoea and abdominal cramps. The man blames this on the side effects of the drug while his wife thinks she is developing a malaria attack. What are your reflections?
- Rotterdam. A Dutch woman returned from Laos 6 weeks ago. Might her discomfort in the liver region be explained by the presence of hypnozoites?
- Amsterdam. A Dutch man returned 8 weeks ago from a world tour. Three weeks ago he was successfully treated by you for P. ovale malaria. Is the infection definitively cured? What if this was a P. vivax malaria? Can a P. vivax malaria attack still occur after this treatment, and if so how long afterwards? Is this important if one day he wants to give blood?
- Gabon. Would you advise a priest who was treated last year in Belgium for tropical splenomegaly syndrome, to take malaria chemoprophylaxis for a long period?
- Malawi. A Danish development worker has been taking chloroquine/proguanil as chemoprophylaxis for 18 months. She has never had malaria. She feels great, but is complaining of small painful and recurring ulcers on her oral mucosa. Do you need any further information?
- Vietnam. During the Vietnam war American soldiers took what was called the CP-pill once a week. This contained 300 mg chloroquine and 45 mg primaquine base. The results as regards malaria prophylaxis were disappointing. Can you think of some reasons for this?
- Southeast Asia. After working for a long time in a rural area, you notice that there are fewer malaria cases in families which keep their water buffaloes and cattle around their houses at night or where the pigs sleep under the stilts of their dwellings. Some ideas of what might be happening here?
- Vietnam. An important local vector is Anopheles dirus, a mosquito which is very sensitive to light and thrives well in the forest. In many places the forest has been felled and replaced by commercial plantations of fruit or rubber trees. The latex is tapped from Hevea brasiliensis very early in the morning, preferably before sunrise. The latex is placed in coconut shells which are thrown away on the ground after use. What might be the possible effect of this activity upon malaria transmission?
- India. The anti-malaria product Mekalfin (= sulphadoxine 500 mg + pyrimethamine 25 mg per tablet) is often sold over the counter. Each box contains 2 tablets. What might be the consequences of this on the efficacy of Fansidar on P. falciparum? Any comments?
- Germany. After a quarrel a woman swallowed 15 chloroquine tablets in a suicide attempt. Two hours later she is in a coma. Her blood pressure is 80/?. Do you insert an endotracheal tube and organise oxygen and stand-by mechanical ventilation? Do you insert an IV line and give physiological fluid? Do you administer 60 mg Valium IV? Do you give adrenalin? Do you carry out gastric lavage?
- Thailand. An adult man weighing 65 kg (blood volume approximately 5 litres) has parasitaemia of 5% P. falciparum (not resistant to Riamet®). Say he has an RBC of 4,000,000 per µl. How many parasites does he have in his body? If he is treated with a three-day course of co-artemether and it is assumed that only artemether is responsible for destruction of the parasites in the first 3 days, how many parasites will lumefantrine remain after day three ?
