A 34-year-old woman comes to the emergency department due to 6 days of fatigue and intermittent fever. Medical history is significant for depression. She does not use tobacco, alcohol, or illicit drugs and has no drug allergies. The patient lives in New York City and recently traveled to central Africa, where she helped establish a nutrition program. Her blood microscopy findings are shown in the exhibit.
Urine pregnancy test is negative. Which of the following is the best treatment for this patient?

Question

A 34-year-old woman comes to the emergency department due to 6 days of fatigue and intermittent fever.  Medical history is significant for depression.  She does not use tobacco, alcohol, or illicit drugs and has no drug allergies.  The patient lives in New York City and recently traveled to central Africa, where she helped establish a nutrition program.  Her blood microscopy findings are shown in the exhibit.  
Urine pregnancy test is negative.  Which of the following is the best treatment for this patient?

Quizplus · Accepted Answer

11ec160b_3841_a45c_9249_ff58bf515c2c_MD0001_00 Although fever and fatigue are nonspecific symptoms, this patient's peripheral blood smear is diagnostic of malaria, a disease endemic to Africa and Latin America that is caused by 4 main species of Plasmodium. The diagnosis is frequently made by examination of a peripheral blood smear with Giemsa staining. In Plasmodium falciparum infection, red blood cells have multiple small rings representing developing trophozoites (arrows) and banana-shaped gametocytes (not shown). For malaria acquired in areas known to have chloroquine-sensitive organisms, chloroquine is the treatment of choice. Many African species are chloroquine-resistant; these can be treated with atovaquone-proguanil or artemisinins, which are well tolerated and have excellent cure rates. P vivax and P ovale have dormant liver forms (hypnozoites) that require the addition of primaquine therapy. (Choice B) Early disseminated Lyme disease is associated with neurologic (eg, facial nerve palsy) and cardiac (eg, atrioventricular block, carditis) manifestations and is often treated with ceftriaxone. Ixodes scapularis, the tick that transmits Lyme disease, can also transmit babesiosis and ehrlichiosis, which can be treated with doxycycline. Although Babesia can appear as ring-like structures within blood cells, it is differentiated by the presence of 4 rings arranged in a Maltese cross pattern, which is pathognomonic for the disease. (Choice C) P falciparum is the predominant malaria strain in Africa. Most P falciparum in Africa are resistant to chloroquine, so alternate agents (eg, atovaquone-proguanil, artemisinins) are required for treatment. Because P falciparum does not have a dormant hepatic phase, primaquine is not required. (Choice D) Entamoeba histolytica is an amebic parasite that can cause dysentery (bloody diarrhea) and extraintestinal abscess in the liver (most common), lung, or brain. It is typically treated with metronidazole, to kill the trophozoites, and paromomycin, to eliminate residual cysts in the gastrointestinal lumen. (Choice E) Trimethoprim-sulfamethoxazole is used to treat Pneumocystis pneumonia, which is most common in individuals with untreated AIDS or those taking chronic steroids. Patients usually present with slowly worsening dyspnea, dry cough, hypoxia, and diffuse interstitial infiltrates. Educational objective: Red blood cells filled with multiple, small rings suggest Plasmodium infection (malaria). Erythrocytic forms of this parasite may be treated with antimalarials such as chloroquine (in non-resistant areas), atovaquone-proguanil, and artemisinins. Primaquine is required to kill P vivax and P ovale liver hypnozoites. __________ References: Guidelines for the Treatment of Malaria. (http://www.ncbi.nlm.nih.gov/pubmed/26020088)

A 34-Year-Old Woman Comes to the Emergency Department Due to 6