The Long Sleep

A 34-year-old woman presents to an urgent care clinic with five days of high fevers, shaking chills, severe frontal headache, profound myalgias, and fatigue. The fevers have been occurring every other day with striking regularity. When the clinician asks about recent travel, she mentions a three-month humanitarian aid mission to rural Papua New Guinea that ended six months ago. She adds that she does not think it could be related because she took her malaria prophylaxis every day while she was there and for a week after returning, and has felt completely well since. She has no significant medical history, takes no medications currently, and is not pregnant.

On examination, temperature is 38.9°C, heart rate 112/min, blood pressure 104/68 mmHg, respiratory rate 18/min, and oxygen saturation 98% on room air. She appears ill and fatigued. The spleen tip is palpable 2 cm below the left costal margin. No jaundice, no lymphadenopathy, and no skin rash are identified.

Laboratory studies show white blood cells 4.8 x 10^3/uL with a mild relative lymphocytosis, hemoglobin 10.8 g/dL (normocytic), platelets 98 x 10^3/uL, total bilirubin 1.8 mg/dL, LDH 312 U/L, creatinine 0.9 mg/dL, and ALT 44 U/L. Thick and thin Giemsa-stained blood smears are positive for malaria; the infected erythrocytes are enlarged and contain ameboid trophozoites with fine eosinophilic stippling of the red cell membrane. A rapid diagnostic test is positive for pan-Plasmodium lactate dehydrogenase (pLDH) and negative for P. falciparum-specific HRP2. Malaria PCR is sent and confirms the species. The prophylaxis she took in Papua New Guinea was atovaquone-proguanil.