The 41-year-old man eased his car into a spot in front of a chain drugstore at the northern edge of Albuquerque. He felt awful. Suddenly he began to shiver, then shake. He watched helplessly as his arms, his legs, his entire 6-foot-5-inch body jumped and jolted like a rag doll shaken by a child. When the shivering stopped, the air-conditioned car suddenly felt as hot as the desert air outside. Nausea swept over him, and he opened the door just in time to vomit the little he’d been able to eat.
He had felt sick for days. Earlier that week, he went for a walk with his wife through the beautiful mountain town of Durango, Colo., where they lived. It was a walk they did all the time, yet that day he felt heavy — as if he were wearing a backpack. Just lifting his feet was an effort. Before he left town, he took a Covid rapid test — just in case. It was negative. Then he drove to Albuquerque to compete in a long-anticipated golf tournament. The day of the competition, his whole body ached, but he loaded himself up with acetaminophen and ibuprofen and muscled his way through the 36 holes. He felt too sick and too tired to attempt the four-hour drive home that afternoon. He took another Covid test — it was again negative — then checked himself in to a hotel to sleep it off.
It was an awful night. Fever and chills culminated in sweats that twice soaked through his T-shirt. He finally slept, waking at checkout time to head home. Entering the highway, he had second thoughts. The road between Albuquerque and Durango was isolated. There were few gas stations, and no cell service for a good part of the way. He pulled over into the drugstore parking lot to consider his options, and that’s when the bone-rattling chills set in. No question about it, he was sick.
He drove to the closest urgent-care center. They confirmed that he had a fever, but because there wasn’t a lab on the premises, they couldn’t tell him much more. He found a nearby hotel and hoped for a better night. He didn’t get one. As soon as it was light outside, he headed for the E.R. at the University of New Mexico Hospital.
Plummeting Platelets
As he waited, the man took his temperature with a thermometer he brought with him from home. It was 103. But by the time he was seen, hours later, it was down to normal. He felt sick but couldn’t really say what hurt. He was given IV fluids, which helped. The nurse told him he probably had some kind of virus, and she suspected he would be discharged once they got the labs back.
Instead, the blood work showed that his platelet count was dangerously low. Platelets are the blood cells that initiate clot formation. Normally we have from 150,000 to 400,000 platelets per microliter of blood. He had only 41,000. The E.R. doctor reassured him that the risk of spontaneous bleeding wasn’t significant until there were fewer than 20,000 platelets. More worrying, he told the patient, was his high level of bilirubin, a breakdown product of red blood cells. Something was destroying his blood. He was admitted to the hospital.
The next morning, Dr. Suman Pal, the hospitalist assigned to his care, went to see his newest patient. Just looking at him, he could see that he was normally healthy but pretty sick now. He was jaundiced — his skin and eyes yellowed from rising levels of bilirubin. And he moved restlessly in the bed, as if he couldn’t find a comfortable spot. He had a fever overnight but otherwise the only new finding was a faint rash that came from his low platelet count. That count had dropped to 20,000, and his bilirubin had nearly doubled.
When the patient heard that his platelets had dropped to the level he was told would put him at risk for bleeding, he called his wife. He had been telling her not to come to Albuquerque because it was probably “just a virus,” but now he was worried. I’m not going to die in this hospital, he told her on the phone. She immediately headed to Albuquerque.
Cognitive Decline
Pal came back in the afternoon to tell the couple that the blood smear, ordered to find out what was destroying his red blood cells, had shown the presence of many tiny ring-shaped organisms inside those cells. There were two possibilities: babesia — a tick-borne parasite seen mainly in the Northeast and upper Midwest in the United States — or malaria, a mosquito-borne infection that is common in much of the world but not here in this country. Had he traveled outside the U.S.? Yes, he’d been to London and parts of Scotland just a couple of weeks earlier to visit his family. And shortly after that he and his wife went hiking in Montana. Malaria isn’t common in any of those places. And while babesia has never been reported in Colorado and only once in the past five years in Montana, it had certainly been seen in other states across the U.S. Babesia microti is a parasite that, like malaria, invades red blood cells to reproduce. It then bursts the cell open to release a new generation of invaders, which then hijack even more cells. Infection with this parasite often causes high fevers, low platelet counts and high levels of bilirubin. Given his travel history, Pal told the couple, that was the most likely diagnosis. They would start treating him for babesiosis with the two antibiotics recommended by the C.D.C.
When his wife returned the next morning, the patient seemed even sicker. He was more yellow and was now having trouble finding the right word. That embarrassed him and worried his nurse, Getachew Gobena, who had spent 15 years caring for malaria patients in different parts of Africa as well as his native Ethiopia.
Gobena was worried that this wasn’t babesiosis at all. The ring forms seen in the lab here were just like those he’d seen in patients sick with malaria. In his experience, the diagnosis of malaria was often based on symptoms alone — and this man had those symptoms. His confusion was particularly worrisome.
Give the treatment time to work, the doctors urged the patient’s wife. But when he didn’t recognize her that afternoon, she felt a stab of terror. He wasn’t getting better. As unlikely as the doctors said this was, could it be malaria after all?
Pressing an Unlikely Diagnosis
Gobena needed no persuasion. As he watched the patient deteriorate, he was determined to make his case to the infectious-disease specialist as soon as he had the chance. Passing the patient’s room later that day, he heard the voice of Dr. Mark Lacy, the infectious-disease doctor covering that weekend. He showed Lacy pictures of the rings seen in the blood smear and shared his concerns. Lacy had spent several years working in Indonesia, where he saw a lot of malaria. He agreed: The pictures were worrisome for malaria. He made his way to the lab to look at the slides himself. As unlikely as it was, Lacy felt certain the patient had malaria.
Hearing that, Gobena made a point of giving the patient the first dose of his antimalarial drug before he went home that night. He had seen how quickly patients can deteriorate — especially once they become confused.
The next morning, the patient’s wife was amazed to see how much better he looked. She approached his bed and asked the question she hoped he could answer: “Do you know who I am?” He paused for a moment.
“Of course,” he answered. “You are my beautiful wife.” Tears ran down her face. She recognized him too. He was back.
The results of the genetic test of the bug came back a few days later. It was malaria — and the most deadly version of that disease. By the end of the week, he was well enough to go home. Full recovery, however, took weeks more. There are 2,000 cases of malaria in the United States every year. Almost all occur in people returning from areas where malaria is common. But there are cases in which the source of the infection remains a mystery. In the literature, it’s known as airport malaria because in the first published cases the transmission was linked to airports where flights to endemic regions were common. Was he infected in an airport? We’ll never know. The only thing we can say for certain is that unlikely is not the same as impossible.
Lisa Sanders, M.D., is a contributing writer for the magazine. Her latest book is “Diagnosis: Solving the Most Baffling Medical Mysteries.” If you have a solved case to share, write her at Lisa.Sandersmd@gmail.com.
