A 64 yo male with a history of IDDM presents with generalized fatigue. He felt so weak last night that he missed his pm dose of Lantus and vomited this morning. He arrived with a critically elevated BG of 590. He flew to the US from Sierra Leone 3 days ago.
Labs include:
Wbc 3.5 Plt 34 Hb 12 Hct 36
Na 125 CL 93 Co2 14 K 4.5 BUN 25 Cr 1.9 Glu 590 AG 18
VBG pH 7.23
Clinical Question:
Other than treating his diabetic ketoacidosis and renal failure, would you send any further tests?
Answer:
Thick smear for Malaria.
Bottom Line:
DKA is often a symptom of an underlying metabolic or infectious insult
Have a high suspicion for malaria in those travelers coming from endemic regions and don't forget malaria symptoms are often insidious presenting with myalgia and fatigue, as well as the traditional undulating fevers and chills
In addition to anemia, thrombocytopenia has been seen in P. vivax and P. falciparum. (In the at-risk traveler, this finding should raise your suspicion for malaria.)
University of Maryland Section of Global Emergency Health
Author: Bradford Schwartz, MD
References
Ansari, Khoharo, Akhund, and Qureshi. Thrombocytopenia in plasmodium falciparum malaria.J Ayub Med Coll Abbottabad. 2009 Apr-Jun;21(2):145-7.
Kumar and Shashirekha. Thrombocytopenia--an indicator of acute vivax malaria. Indian J Pathol Microbiol. 2006 Oct;49(4):505-8.
Lacerda, Mourao, Coelho, and Santos. Thrombocytopenia in malaria: who cares? Mem Inst Oswaldo Cruz. 2011 Aug;106 Suppl 1:52-63.
