What caused young man's high fever?
"105.5 hurt a lot!"
When 22-year-old Marc Fenigstein arrived in the emergency room for the third time, his fevers were out of control.
"I was shivering so hard, I couldn't straighten my legs, and my muscles started cramping up; I just couldn't get warm," the mechanical engineer said in a recent interview.
What began as a mild "flulike" illness managed by ibuprofen and rest had now turned into shaking chills and high cyclic fevers.
"I would feel totally fine one day and then at night I would start sweating," Fenigstein said. "I soaked through towels with sweat at night."
Eventually, blood tests revealed Fenigstein's platelets were low, he was anemic and his white blood cells were slightly elevated. He was also beginning to complain of a stiff neck. He had lost 5 pounds.
Doctors were concerned. For someone his age with those symptoms, the likely diagnosis was "bacterial meningitis, influenza, acute HIV, strep throat or mononucleosis," according to Dr. Stephen Walsh, an infectious disease specialist at Massachusetts General.
Fenigstein's spinal tap was negative for bacterial and viral meningitis. His blood and throat cultures were negative. He also did not have HIV or influenza.
But the cause of his fevers remained a mystery for nearly two weeks.
Finally, on his third trip to the emergency room, Fenigstein's doctors realized a key fact: Three months earlier, he had gone trekking in the mountains of Peru and the jungles of Ecuador.
During his six-week adventure trip, he played soccer barefoot and developed a rash on the soles of his feet. Despite wearing DEET insect repellent, he had been bitten by mosquitoes. He had eaten local food and fruit, and had a bout of diarrhea.
But what was causing his high fevers now, several months later?
Pathologists stained a blood smear and found parasites invading his red blood cells; the protozoa that kill more than 1 million people worldwide each year: Fenigstein had malaria.
An infected mosquito in South America (likely more than one) had bitten and injected the malaria organisms under Fenigstein's skin. Once there, the parasites traveled to his liver, where they matured and then reinvaded his blood.
Usually, symptoms will begin within weeks of infection. Fenigstein's symptoms had taken months to appear.
His fevers were tied to the life cycle of the malaria organism. Every 24 to 48 hours, the parasites would break out of the red blood cells releasing a new generation of bugs and inflaming his body with fever.
The malaria organisms are very smart.
"They have brilliantly evolved to live in our red blood cells where they can hide from our immune systems and they have an excellent food supply of hemoglobin," according to Dr. Johanna Daily, a malaria specialist at Brigham and Women's Hospital.
"Malaria is usually diagnosed within weeks or months of travel," Walsh said, "but anybody who has traveled to malaria-endemic countries in the past two years and has a fever should be worked up. It is a lesson for all physicians."
Travel is always relevant in medicine; patients need to tell doctors and doctors need to ask, Walsh said. It doesn't matter how long ago the trip was. Infectious diseases and parasites can cause illness years or even decades later. "I always ask people especially about military service because for some reason they don't think of that as travel," Walsh said.
Prevention, detection and treatment of malaria are not 100 percent effective. The antibiotic doxycylcine, which Fenigstein had taken before his trip, fortunately prevented him from getting the deadlier form of malaria called falciparum but it does not always prevent the type he had -- vivax malaria. Once diagnosed, he was prescribed chloroquine to treat the infection and primaquine to kill off the latent, liver form of the disease.
Unfortunately, Fenigstein did not take the primaquine right away.
"No drug stores in my neighborhood carried it," he said. "I had to order it and then I went to visit my grandparents in New York. The fevers started all over again."
Sure enough, his malaria had returned.
"He called me from the Brooklyn Bridge and said, `I think I have malaria again,' " said Walsh, who was in Boston. He told Fenigstein to go to the closest hospital in New York.
This time, the world traveler completed a full course of both medications.
"I am going to be more on the ball about taking care of everything before and after I travel and watching for any symptoms I might have," Fenigstein said recently, more than a year after his full recovery. "In fact, I am going to Southeast Asia in the spring and I am talking to Dr. Walsh soon."
More information on malaria is available at www.cdc.gov/travel. A version of this case first appeared as part of the Massachusetts General Hospital Case Records in the New England Journal of Medicine. Dr. Terry Schraeder can be reached at tschraeder@cox.net.
