An otherwise healthy 43-year-old male patient presented to the ED on 1/5 around 6:20 p.m., complaining of a 5-day history of illness, with fever, shortness of breath, fatigue, cough, headache, and body aches. He reported having returned from a trip to Morocco and Sierra Leone just before Christmas. In the ED, his temperature was 39.6, BP 99/62, HR 120, RR 28, and O2 sats 99%. The patient was noted to be pale and diaphoretic. A CT abdomen/pelvis showed hepatosplenomegaly and hepatic steatosis, but other imaging was unrevealing. Labwork showed lactic acid of 4.3, platelets at 19, sodium 126, BUN 59, creatinine 3.8, total bilirubin 2.8, AST 179, ALT 129, D-Dimer 13.47. He was started on IV fluids and Ceftriaxone, and admitted around midnight. The admitting H&P noted that the patient had gone to 2 freestanding urgent care centers in the day before admission, and had tested negative for Covid and influenza.
At 5:02 the morning of 1/6, the hospitalist entered orders for a malaria smear as well as testing for Dengue, Zika, and Chikungunya. A STAT Infectious Disease consult was also requested around this time. The Infectious Disease consult was done at 8:46 by an ARNP, who noted that the testing was pending and started the patient on PO doxycycline.
On 1/7 at 12:10 p.m., a pathologist called the hospitalist to discuss that the malaria smear showed multiple malarial trophozoites, suspicious for P. falciparum. The pathologist also noted that the patient had thrombocytopenia, and his peripheral white cell findings showed a shift to the left consistent with an acute inflammatory response. The Infectious Disease APRN noted at 1:17 that testing had been positive for P. falciparum malaria; "will start him on Malarone." The order for Malarone was not entered until around 4 p.m., and the patient received his first dose at 5:18 p.m.
On 1/8, the hospitalist noted that he had discussed the case with a doctor at the CDC in Atlanta, and that artesunate would be shipped from there for the patient. The artesunate arrived later that day, and the patient received his first dose via IV around 6 p.m. Later testing results from the state lab showed that as of 1/6 (the day after presenting to the ED), the patient's blood had around 80% parasitemia.
The patient went into multiorgan failure and suffered a splenic infarction, requiring a splenectomy. He spent several months in the hospital and received at least 10 units of blood, but did eventually survive.
My questions are, did it take too long to diagnose and treat the patient? Should the hospital have had artesunate available or gotten it sooner? And would any of this likely have made a difference in terms of the splenectomy, in particular? If you can't answer based on the information I gave, what would you need to know? Thank you!
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No questions yet!
Do you believe there might have been medical error?
The suspicion for malaria was done within first 24h of seeing the patient, the smears was read correctly, the malarone order was done since it is the only available medication in the hospital and the artesunate is likely not available until CDC authorizes it. I do not see any departure from common medical care. Unfortunately, patient had severe malaria. Did he take prophylaxis? Prophylaxis against malaria is highly effective, this could have save the patient all this problem.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I do not believe so. Causation would be if nobody would have thought about malaria until splenectomy.
What makes you a good expert for this case?
Expert on tropical medicine, certified in the us
How often do you encounter cases similar to this one in your practice?
All the time since i am consulted for all malaria cases in the hospital for the last ten years
Do you believe there might have been medical error?
This patient had plasmodium falciparum malaria. There was a modest Delay in treatment but I don’t think that treatment started four or eight hours earlier would’ve led to a difference in clinical outcome. He already had a lactic acidosis and severe thrombocytopenia indicating advanced infection. A malaria smear actually underestimates the amount of parasites in the body and the fact that there were numerous organisms seen means he already had an advanced infection. The doxycycline started early in the day likely would of some positive benefit . The standard of care for malaria diagnosis and treatment in the United States is not particularly rigorous. Is this scenario described as common and giving antimalarial treatment even eight hours probably would not have led to a different outcome. It would be difficult to prevail on this in court
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above this is an unfortunate outcome of this case of malaria it is not uncommon in probably is standard of care in a community where Larry is a very rare disease.
What makes you a good expert for this case?
I am one of the leading malaria experts in the United States. I’ve seen many cases of malaria and Principal investigator of a nih funded Malaria center of excellence based in South America for the past 14 years. I’m also certified in clinical tropical medicine and generally recognized as a leader in tropical medicine in the United States.
How often do you encounter cases similar to this one in your practice?
Once to twice a year In the United States but also in Peru where I work as well where I see more cases in the field setting in the Amazon
Do you believe there might have been medical error?
I think the major issues in this case are the time between when the parasite smear was sent and when a result returned, and the time to start artesunate. A parasite smear is a simple test that only takes a few hours to perform, so it's not clear to me why it took 30 hours to return, unless this was done at a small hospital and it needed to be sent out to a reference lab. Also, after the smear returned positive, artesunate should have been ordered immediately, since this patient met the definition of severe malaria. It's not unusual for hospitals to not stock artesunate and to need to order it from the CDC. Also, artesunate was approved by the FDA in 5/2020 so if this case occurred before then, the CDC was the only source for the drug.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I don't think it's possible to definitely argue that, since the risk of complications is high with that degree of parasitemia even when starting effective therapy sooner.
What makes you a good expert for this case?
I'm an infectious diseases physician in practice for 9 years.
How often do you encounter cases similar to this one in your practice?
I see malaria rarely, about once per year.
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