Diagnosing Malaria †Case Study

Diagnosing Malaria – Case Study Free Online Research Papers Diagnosing malaria can be missed when there is a significant time lag from exposure and negative initial tests. As clinicians we must always consider the diagnosis in the appropriate clinical setting as a missed diagnosis can potentially result in serious consequences. A 27 year old female student from Nigeria presented with a two day history of headaches, mild photophobia, sweats and fever. She arrived from Nigeria eight months previously and had not been back since. On admission she was unwell with a temperature of 38.5?C, pulse 110/min but otherwise haemodynamically stable. Examination revealed a soft ejection systolic murmur and signs of meningism, but her neurological assessment was otherwise entirely normal. Her initial investigations showed a haemoglobin level of 11.8g/dl, white cell count 3.9109/l, lymphocytes 0.5109/l, platelets 118109/l, C-reactive protein 121mg/l; urea and electrolytes and liver function tests were normal. She was commenced on ceftriaxone 2g daily with a presumptive diagnosis of meningitis. She had a normal CT head, which was followed by a normal lumbar puncture. Two sets of blood cultures and a mid-stream urine sample had no growth after 48 hours. The initial admission pyrexic thick and thin blood film and malarial antigen test (Optimal, DiaMed) were negative. She improved initially with antibiotics and intravenous fluids. 24 hours into her admission, having been reviewed by a number of senior doctors, her working diagnosis was changed to one of a viral illness and plans were made for her discharge. Malaria was felt to be unlikely given that not only was she eight months post exposure for malaria, her blood film and antigen test were negative. However, on the day of discharge she was found to spike a temperature of 38?C and remained thrombocytopenic (108109/l). It was decided that in view of her origin (Nigeria) and the fact that she remained thrombocytopenic, malaria still needed to be considered. Even though a thick and thin blood film and malarial antigen test (Optimal, DiaMed) were negative, we felt three negative blood films were needed before excluding malaria and labelling her as a patient with a viral illness. Interestingly a repeat blood film showed malarial parasitaemia of 5% Plasmodium falciparum [Figure 1]. Her haemoglobin dropped to 9g/dl and platelets dropped to 93109/l over the next two days, which then recovered. She was treated with intravenous quinine (10mg/kg) for 48hrs and converted to oral quinine for seven days followed by three tablets of oral pyrimethamine with sulfadoxine (Fansidar). She was discharged home with a negative parasitaemia. Comment The Office of National Statistics reports increasing international travel in our population with 25 million visitors to the UK and 61 million trips abroad in 2003. According to the Health Protection Agency (HPA) there were 1722 cases of malaria in the UK in 2003, 78% were Plasmodium falciparum, all of which were diagnosed within five months of arrival in the UK. Their statistics also show that 59% of malarial cases in UK are from those of African ethnicity, and patients who were infected in Nigeria contribute one third of all Plasmodium falciparum cases in UK and 2 out of 16 deaths in 2003. Immunity to malaria is acquired slowly, is incomplete and on leaving the infectious environment falls over about 1-2 years. Those who have been out of exposure for greater than 1 year or been born in UK are classed as non-immune. These individuals if exposed usually develop malaria within one month of leaving the endemic area. In contrast those who are from endemic areas and arrive in the UK as an immigrant, visitor or student (our patient) are classed as semi-immune. In these individuals and those who have taken malaria prophylaxis, incubation can be significantly prolonged, and may have milder symptoms. In those countries with high transmission rates, severe disease is usually a disease of the young (1 month to 5 years) or non-immune adults (vast majority of travellers to endemic areas). Children in areas of high transmission often show tolerability of the parasites due to constant parasitaemia without signs of disease, and paradoxically those living in low transmission areas have high clinical disease burden 1. Reviewing the HPA statistics, of the 1722 cases reported in 2003, 52% were visiting family and friends in their country of origin and probably non-immune as they had been born or lived in the UK for some time, 22% were from endemic areas (immigrants, visitors, students), and 26% were almost certainly non-immune (business travel, holiday, expatriates). Diagnosis of malaria in the 22% group, who arrive from an endemic area and are semi-immune, is often difficult because they can present late with clinical malaria, as demonstrated with our patient being in the UK for eight months prior to presentation. Our case was notable in that our patient had an initial negative microscopy and malaria antigen test. The latter is a new method for detecting malaria. It is a rapid dipstick immunoassay that detects circulating antigens of either histidine rich protein-2 of falciparum (HRP-2f) or plasmodium lactate dehydrogenase (pLDH). These are near-patient testing kits that have recently been developed to ease and speed up diagnosis, particularly in places that do not have access to microscopes or trained laboratory staff. The malarial antigen test Optimal (DiaMed) used in this case detects presence of pLDH. This assay can detect parasitaemia levels of 100-200 parasites per ?L of blood, equivalent to 0.002% 2 and has been found to have a sensitivity of 95.3% and a specificity of 100% for Plasmodium falciparum 3. However, a meta-analysis of ten popular brands showed that HRP-2 was more accurate than the pLDH tests 4. Though quick to use and easy to read they are not as accurate nor as good at dete cting species as microscopy using thick and thin films, hence why microscopy remains the method of choice. We believe most general physicians would have felt that on initial presentation our patient was unlikely to have malaria. She presented with non-specific symptoms and signs of meningism; over eight months had elapsed since her return from Nigeria and lastly initial investigations were negative for malaria. Many might have put her presentation down to a viral illness, though she had the characteristic lymphopenia and thrombocytopenia for malaria (sensitivity for thrombocytopenia in those with malaria is 60%, and specificity is 95%) 5. It is noteworthy however that a study in Nigeria found that headache, fever, chills and rigors were the commonest malaria symptoms in adults6. Further, a fact that we all forget is that the HPA advises us to consider malaria in a patient who has been potentially exposed up to 12 months. Finally if the clinical suspicion for malaria is high, three sets of malarial blood films must be taken before suggesting a negative result – easily forgotten by clinicians. In conclusion we would like to reinforce to all clinicians the advice by the Health Protection Agency that it is important to consider malaria due to Plasmodium falciparum as a differential in those who have had malaria exposure in the last 12 months and to always take three blood films if there is any clinical suspicion to make a diagnosis of malaria. Figure 1: Patients blood film showing malarial parasites References: 1. Reyburn H, Mbatia R, Drakeley C, Bruce J, Carneiro I, Olomi R, Cox J, Nkya WMMM, Lemnge M, Greenwood BM, Riley EM Association of Transmission Intensity and Age With Clinical Manifestations and Case Fatality of Severe Plasmodium falciparum Malaria Journal of American Medical Association 2005; 293:1461-1470 2. Palmer CJ, Lindo JF, Klaskala WI, Quesada JA, Kaminsky R, Baum MK, Ager AL Evaluation of the OptiMAL Test for Rapid Diagnosis of Plasmodium vivax and Plasmodium falciparum Malaria Journal of Clinical Microbiology 1998; Jan: 203-206 3. Kolaczinski J, Mohammed N, Ali I, Ali M, Khan N, Ezard N, Rowland M Comparison of the OptiMAL rapid antigen test with field microscopy for the detection of Plasmodium vivax and P. falciparum: considerations for the application of the rapid test in Afghanistan Annals of Tropical Medicine and Parasitology 2004; 98(1): 15-20 4. Marx A, Pewsner D, Egger M, Nuesch R, Bucher HC, Genton B, Hatz C, Juni P Meta-analysis: accuracy of rapid tests for malaria in travelers returning from endemic areas Annals of Internal Medicine 2005; 142(10): 836-46 5. DAcremont V, Landry P, Mueller I, Pecoud A, Genton B Clinical and laboratory predictors of imported malaria in an outpatient setting: an aid to medical decision making in returning travelers with fever American Journal of Tropical Medicine and Hygiene 2002, 66: 481-486 6. Harrison NE, Odunukwe NN, Ijoma CK, Mafe AG Current clinical presentation of malaria in Enugu, Nigeria Nigerian Postgraduate Medicine J. 2004; 11(4): 240-5 Research Papers on Diagnosing Malaria - Case StudyPersonal Experience with Teen PregnancyStandardized TestingResearch Process Part OneWhere Wild and West MeetLifes What IfsThe Relationship Between Delinquency and Drug UseEffects of Television Violence on ChildrenRelationship between Media Coverage and Social and19 Century Society: A Deeply Divided EraMarketing of Lifeboy Soap A Unilever Product

The History of Figure Skating and Ice Skates

The History of Figure Skating and Ice Skates Historians generally agree that ice skating, what we also today call figure skating, originated in  Europe several millennia ago, though its unclear when and where the first ice skates came into use. Ancient European Origins Archaeologists have been discovering ice skates made from bone throughout Northern Europe and Russia for years, leading scientists to posit that this method of transport was at one point not so much an activity as a necessity. A pair pulled  from the bottom of a lake in Switzerland, dated back to about 3000 B.C., are considered to be one of the oldest skates  ever found. They are made from the leg bones of large animals, with holes bored into each end of the bone into which leather straps were inserted and used to tie the skates to the foot. It is interesting to note that the  old Dutch word for skate is schenkel, which means leg bone. However, a 2008 study of northern European geography and terrain concluded that ice skates likely appeared first in Finland  over 4000 years ago.  This conclusion was based on the fact that, given the number of lakes in  Finland, its people would have had to invent a time-saving way to navigate across the country. Obviously, it would have saved precious time and energy to figure out a way to cross the lakes, rather than circumnavigate them. Metal Edged These early European skates didnt actually cut into the ice. Instead, users moved across the ice by gliding, rather than by what we have come to know as true skating. That came later, around the late 14th century, when the Dutch started sharpening the edges of their formerly flat-bottomed iron skates. This invention now made it possible to actually skate along the ice, and it made poles, which previously had been used to aid in propulsion and balance, obsolete. Skaters could now push and glide with their feet, a movement we still call the Dutch Roll. Ice Dancing The father of modern figure skating is Jackson Haines, an American skater, and dancer who in 1865 developed the two-plate, all-metal blade, which he tied directly to his boots. These allowed him to incorporate a host of ballet and dance moves into his skating- up until that point, most people could only go forward and backward and trace circles or figure eights. Once Haines added the first toe pick to skates in the 1870s, jumps now became possible for figure skaters. Today, increasingly spectacular leaps and bounds are one of the things that have made figure skating such a popular spectator sport, and one of the highlights of the Winter Olympic games. Sporting Developments  was developed in 1875 in Canada, although the first  mechanically refrigerated ice rink, named the Glaciarium, was built in 1876, at Chelsea, London, England, by John Gamgee.   The Dutch are also likely responsible for holding the first  skating competitions, however, the first official speed skating events were not held until 1863 in Oslo, Norway. The  Netherlands hosted the first World Championships in 1889, with teams from Russia, the United States, and England joining the Dutch. Speed skating made its Olympic debut at the winter games in 1924. In 1914, John E. Strauss, a blade maker from St. Paul, Minnesota, invented the  first closed-toe blade made from one piece of steel, making skates lighter and stronger. And, in 1949, Frank Zamboni trademarked the ice resurfacing machine that bears his name. The largest, man-made outdoor ice rink is the Fujikyu Highland Promenade Rink in Japan, built in  1967. It boasts an ice area of 165,750 square feet, the equivalent of 3.8 acres. It is still in use today.