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A 40 year old man, resident of the United States, presents to an emergency room with a 5-day history of fever, chills, nausea, vomiting, and myalgias. He returned 2 weeks ago from a 16-day visit to Zambia.

Question 1: What chemoprophylaxis regimen (if any) should be recommended for travel to Zambia? (more than one might apply)

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Question 2: Based on the observed time intervals, could the symptoms experienced by the patient be due to malaria?

Some days later, the patient was seen at another clinic, where on a routine CBC malaria parasites were seen. He was then referred to a hospital, where he presents to the emergency room, at 4 am, with continuing fever, nausea, vomiting, and myalgias. On physical examination, the patient is febrile (102°F), tachycardic. jaundiced and pale. He is well oriented but slow in answering questions. A thin blood smear obtained while in the emergency room is read as Plasmodium, species not determined. Other laboratory findings include: hematocrit 33% , creatinine 3.6 mg/dL, and total bilirubin 11.0 mg/dL. The urine is dark, with a measured output of 40 mL/6 hours.

Question 3: What would be the best next step in the clinical management of this case?

The patient is admitted to the medical intensive care unit and treated with oral quinine and doxycycline. Later that day, the blood smear is reviewed by more experienced personnel for speciation.

An autopsy was performed, but after a delay of 8 days. The gross findings show a slight swelling of the cerebral gyri, with consequent narrowing of the sulci; some blood vessels are engorged, with scattered petechial hemorrhage. The hematoxylin-eosin section of the brain shows autolysis, some pycnotic nuclei, and scattered pigment felt to be malarial in origin. The pigment and pinpoint hemorrhages are felt to be pre-mortem.