October 19, 2021

A medical mystery: Why was this man's platelet count plummeting?

Daily Briefing

    After experiencing days of fevers and chills, a 41-year-old man was admitted to the hospital with plummeting platelet counts, Lisa Sanders writes for New York Time Magazine—and the cause ended up being an unlikely infection not commonly seen in the United States.

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    Constant fevers and chills send a man to the hospital

    The patient had been feeling sick for days, Sanders writes, to the point where a routine walk with his wife was difficult. Before he left for a golf tournament in Albuquerque, N.M., the patient took a Covid-19 rapid test, but it came back negative.

    At the tournament, the patient's body ached all day, and by the end of the day, he felt too sick and tired to attempt his four-hour drive home to Colorado. He took another Covid-19 rapid test, which came back negative, checked himself into a hotel for the night, and went to the nearest urgent care center in the morning. There, staff confirmed he had a fever, but they could not tell him anything else because they did not have a lab on-site.

    The next morning, still feeling unwell, the patient drove to the ED at the University of New Mexico Hospital. There, the patient's blood work showed his platelet count, which should have been between 150,000 and 400,000, was dangerously low at 41,000. In addition, he had a high level of bilirubin, a breakdown product of red blood cells—indicating that something was destroying his blood, Sanders writes. He was admitted to the hospital.

    The next morning, the patient's platelet count had dropped to 20,000, a level that could put him at risk of spontaneous bleeding, and his bilirubin level had almost doubled. Although he had initially told his wife that it was "just a virus," he now worried about his risk of bleeding and asked his wife to come to the hospital in Albuquerque.

    2 potential causes for the patient's condition

    In the afternoon, Suman Pal, the hospitalist assigned to the patient's care, relayed the results of a blood smear that had been ordered to find out what was destroying the patient's red blood cells, Sanders writes.

    The blood smear showed many tiny ring-shaped organisms inside of the patient's red blood cells, which Pal said could be one of two things: babesia microti, a tick-borne parasite mainly found in the Northeastern and upper Midwestern United States, or malaria, a mosquito-borne infection largely found outside of the United States. According to Sanders, both babesia and malaria invade and destroy red blood cells to reproduce, and infections often cause high fevers, low platelet counts, and high bilirubin levels.

    Although the patient had not traveled to places where either babesia or malaria were common, Pal said babesia was the most likely cause since it was still known to appear in other states across the United States. With that diagnosis, the patient was given two antibiotics recommended by CDC to treat the infection, Sanders writes.

    A nurse pushes for a malaria diagnosis

    However, the next morning, the patient seemed even sicker, Sanders writes, experiencing a more pronounced jaundice and cognitive decline. Seeing the patient struggle, Getachew Gobena, the patient's nurse, was concerned he had malaria instead of babesiosis as initially diagnosed.

    According to Sanders, Gobena had spent 15 years caring for malaria patients in his native Ethiopia as well as other parts of Africa. The patient's symptoms, along with the ring forms in his blood work, were both similar to those of malaria patients Gobena had worked with.

    Gobena shared his concerns with Mark Lacy, an infectious disease specialist at the hospital. Lacy had spent several years working in Indonesia where he saw a lot of malaria, Sanders writes, and after reviewing the patient's information, as well as the original slides, he felt certain the patient had malaria, as unlikely as it was.

    Based on Lacy's assessment, Gobena administered the first dose of an antimalarial drug. The next day, the patient's wife was "amazed to see how much better he looked," Sanders writes, and his cognitive abilities had improved.

    A few days later, a genetic test of the infection came back, confirming it was malaria—and the deadliest form of the disease, Sanders writes. By the end of the week, the patient had improved enough to go home, although it took him several more weeks to fully recover.

    According to Sanders, there are 2,000 cases of malaria in the United States every year, and almost all of them occur in people returning from areas where the disease is common. However, there are still cases, much like the patient's, where the source of transmission is unknown. These cases are known as "airport malaria," since they were first linked to airports with regular flights to regions where the disease is endemic.

    While the source of the patient's malaria may never be known, Sanders writes that "[t]he only thing we can say for certain is that unlikely is not the same as impossible." (Sanders, New York Times Magazine, 10/14)

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