The patient, an otherwise healthy and vigorous middle-aged male, has had several years of intermittent fevers, sweats and a general failure to thrive.

Work up by his PCP is negative and he eventually ends up in my office.

Everything is reasonably normal except for the intermittent fevers. Routine labs (while between episodes) is negative.

The only striking thing is he had spent a decade in the rural Philippines with TNTC bug bites and exposures to everything while there; he ate the food, drank the water, swam in fresh and salt water etc. But he has been back in the states for about a decade

So I figured it was between schistosomiasis and malaria, and if malaria, P. malaraie. I had one case of P. malariae in a patient 2 years after leaving the Philippines.

Schistosoma serology was negative, a thick and thin was negative (when ill) but for hoots and giggles I sent a malaria serology came back positive.

Hmmm. Important? Or not?

So for further hoots and giggles I sent off a malaria PCR, and it was negative for all the malarias as well.

So now what?

I was always impressed with Plasmodium malariae Infection in an Asymptomatic 74-Year-Old Greek Woman with Splenomegaly

which noted

We report a case of malaria due to P. malariae in a 74-year-old woman from Greece whose illness was reactivated after decades of latency. All manifestations were reversed with a three-day course of chloroquine. Although thick and thin peripheral-blood smears were repeatedly negative, a nucleic acid–based assay detected the infecting species of malaria parasite. Since malaria was eradicated from Greece by about 1950, the patient’s infection most likely lasted more than 40 years, possibly as long as 70.



He had mild splenomegaly on CT. So?

I talked it over with the patient, told him I was not really certain he had malaria, but the it may be reasonable to treat. So he recevied a course of chloroquine and primaquine.

And?

All better. He feels great, the best he as in years and has no more febrile spells.

But. I always remember the fifth fallacy in infectious diseases, from the classic everyone should read,

Response implies diagnosis.



As is so often the case, close but not definitive.

Does he or doesn’t he? Got me.

Rationalization

Plasmodium malariae Infection in an Asymptomatic 74-Year-Old Greek Woman with Splenomegaly.

Br Med J. 1923 Jun 30; 1(3261): 1087–1088. PMCID: PMC2316845 THE TREATMENT OF CHRONIC MALARIA. I love old references.

J Travel Med. 2011 Jul-Aug;18(4):288–91. doi: 10.1111/j.1708–8305.2011.00526.x. Epub 2011 Jun 15. Nephrotic syndrome and unrecognized Plasmodium malariae infection in a US Navy sailor 14 years after departing Nigeria. http://www.ncbi.nlm.nih.gov/pubmed/21722243

Acta Trop. 1977 Sep;34(3):265–79. Malaria in the Republic of the Philippines. A review. http://www.ncbi.nlm.nih.gov/pubmed/21558

Clairol Does She Or Doesn’t She. https://www.youtube.com/watch?v=FkxgkquA6sk. For you youngsters