Case Study 4 Revised

ASIAO| SANTOS | SARTE |SOLIS |TALOSIG |
TERRADO | VELASQUEZ | YASIS | YDEL |

ZAMORA
CASE NO. 4
Bruno, a 48-year-old businessman, presents at
the emergency room with a 12- day history of
headache, myalgia, nausea, and vomiting. Patient
history reveals that Bruno is a consulting engineer for
the Panama Canal. On his latest trip, he failed to take his prophylaxis for
malaria. According to his general physician’s records, all his immunizations
(e.g., hepatitis, flu) are up to date. His fever was 103° F (39° C) at the time of
initial examination but alternated with periods of extreme cold and cyanosis.
A complete blood count was ordered, along with parasite examination and
urinalysis. The thin Giemsa film yielded the morphologic forms noted in the
diagram as a, b, and c.
1. How did Bruno contract this parasitic infection?
Bruno had most likely contracted this infection from a mosquito bite during his time at the
Panama Canal, where mosquitoes are known to frequently breed, while he was on his latest trip.
During the initial construction of the Panama Canal during 1904, many workers were
hospitalized due to yellow fever brought on by mosquitoes. There were numerous cases of
malaria as well but it was overshadowed by yellow fever cases at the time due to its relatively
low mortality rate.
Aside from contracting malaria via a bite from an Anopheles mosquito infected by the
Plasmodium species, it is also possible to acquire malaria through other various means.
Examples of these causes include: infected syringes (mainline malaria), transfused blood from
infected donors (transfusion malaria), and congenital reasons. Considering the contents of the
patient’s case study, it is unlikely that he had contracted this infection through these alternative
means.
2. What is the most likely diagnosis and Why?
The most likely diagnosis for the patient is malaria caused by plasmodium parasites carried
by an Anopheles mosquito. The indicated symptoms he had experienced such as fever, chills,
cyanosis, and vomiting match up with the pathological manifestations of malaria fever.
Malaria is a disease that infects and destroys red blood cells. The reduced RBC levels leads to
lower oxygen levels being transported in the blood which in turn causes cyanosis (bluish
discoloration of the skin).
His patient history and travel history which stated that he is an engineering consultant who
works at the Panama Canal as well as the patient’s failure to take a malaria prophylaxis
before going on his latest trip also increases the probability of the diagnosis being malaria.
The Panama Canal is located in a tropical region and on-site operations are mostly done near
the canal itself, making that location an ideal breeding ground for mosquitoes.
3. How can the diagnosis be established?
The diagnosis can be established by performing peripheral blood smears on the patient and examining
the Giemsa-stained films to determine the malaria species and the parasitemia, or the percentage of the
patient’s red blood cells that are infected with malaria parasites through microscopy.
Wright’s stain can be used as an alternative stain that can yield an accurate diagnosis but Giemsa is the
gold standard stain for all blood films submitted for parasite study. A urinalysis can also be performed
to establish or confirm the diagnosis since malarial antigens are known to be released in the urine.
4. Describe the life cycle of the parasite.
Members of the mosquito genus Anopheles are responsible for the transmission of malaria to humans
via a blood meal. This vector transfers the infective stage of the parasite known as sporozoites from its
salivary gland into the human bite wound.
After entering the body, the sporozoites are carried through the peripheral blood to the parenchymal
cells of the liver where schizogony (a.k.a. asexual multiplication) occurs. The exoerythrocytic cycle,
which is done outside of the red blood cells (within the liver cells in particular), lasts from 8 to 25
days, mostly depending on the which Plasmodium species is involved.
The infected liver cells eventually rupture, introducing merozoites into the bloodstream. The
migrating merozoites target specific RBCs to invade and initiate the phase of reproduction involving
RBCs known as the erythrocytic growth cycle. This asexual phase is where the plasmodia start feeding
on the hemoglobin and pass through the numerous stages of growth, including their six morphologic
forms.
4. Describe the life cycle of the parasite. (cont.)
Upon the invasion of the merozoites inside the RBCs, one of three possible outcomes may
occur. Some of the RBCs may end up being part of the erythrocytic growth cycle, while other
infected RBCs containing merozoites develop into microgametocytes and macrogametocytes.
The third outcome is that the infected RBCs are destroyed by the immune system of an
otherwise healthy person.
Transmission of the parasite back into the vector occurs when mosquito ingests mature male
(micro) and female (macro) sex cells of the parasites called gametocytes during a blood meal,
initiating the sexual cycle of growth. The zygote becomes encysted and matures into an oocyst.
Upon complete maturation, the oocyst ruptures and releases numerous sporozoites which
migrate into the salivary gland of the mosquito and are ready to infect another human host,
repeating the cycle once more.
5. How does infection with this parasite occur?
Anopheles mosquitoes that are infected with malarial plasmodium parasites are known
to transmit malaria to human hosts when they engage in blood meals.
Malarial parasites are released into the bloodstream where they travel to the liver to
fully develop. The mature parasites re-enter the bloodstream and starts to infect and
destroy red blood cells several days after the beginning of the infection.
6. What is your management for the patient?
Before finalizing the diagnosis, multiple sets of blood films which consist of thick and thin smears are necessary to rule out
malarial infections as a precaution. It is recommended that blood be collected every 6 to 12 hours for up to 48 hours before
considering a patient to be free of Plasmodium spp.
The patient will be treated with prescription drugs that will kill the malarial parasites in his body. There are parasites are
resistant to some anti-malarial drugs so it is important to be aware of what drugs are to be used for the infecting parasites.
These drugs may be administered orally or intravenously depending on the patient’s health condition and it should always be
administered at the right dose.
Hospitalization, regular monitoring, and additional medication may be necessary for the patient to detect and manage other
additional complications such as the appearance of brown or black urine (hemoglobinuria) or oliguria, which is an indication
of an acute kidney injury.

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ASIAO| SANTOS | SARTE |SOLIS |TALOSIG |

TERRADO | VELASQUEZ | YASIS | YDEL |

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