woman presented with a chief complaint of pain in her left forearm (fractured radius). She had recently arrived in Missouri from Honduras via Texas. She stated that she had fallen and injured her arm when she was fleeing border agents. A routine review of systems revealed a history of fever with shaking chills. In addition to a swollen, tender forearm, she had a temperature of 39.2°C, pallor, and splenomegaly.
Rani
News, Views and More from Batch'64, Faculty of Medicine, Colombo, SriLanka 
Thanks Rani. The history is relevant .Travel from Honduras.Shaking chills and splenomegaly.The blood film shows signet rings and a schizont.The fracture and swelling is a red herring.She has Malaria, I cannot say whether it is p.vivax or P falciparum.i hope my knowledge of tropical medicine has not failed me, as I have not seen a case of malaria for over 35 years. ! Eddie.
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My dear Eddie and Simone
There you see if ever there is one
A well accomplished general physician
My medical knowledge did not help to coin
The patient’s forearm, tender and swollen
Eddie has described the Blood film
As malaria P vivax or Falciparum
Fever with chills and origin Honduras
I bow to both of your knowledge,
As well to our alma marker teaching
Ariya
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Excuse the typo
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I agree with Eddie – Malaria.
In Malaysia, malaria is on the decline & dengue is on the rise. We always use insect repellents & avoid going out into the gardens/.beaches at dusk when the mosquitoes are active And close all windows/doors when the sun is about to set.
Path slides:- Multiple signet rings in one cell & the presence of banana shaped gametocyte suggests that it is most likely to be P.falciparum.
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Sri Lanka I am told has erradicated Malaria and filariasis!
those who knows better please verify. However has become a breeding ground for dengue.
Ariya
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Agree With Eddie. I have not looked at a Path slide in years. Therefore cannot comment much on it.
Nisantha
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Thanks to the participants. All have scored 100% in answering the quiz.I strongly believe as suggested by Ariya ,the Core knowledge acquired at Medical school, is the key to critical thinking in diagnosing this case.
Blood smears revealed P.falciparum
A. Shows an amoboide trophozoite in a large Erythrocyte.
B. A gametophyte with prominent pigment.
C.3 ring trophozoites in a large erythrocte( multiple infected cells are rare)
Blood Hb was 6.6gm/dol
5% reticulocyte
Dual infection with P falciparum and Vivax. Present in Honduras
Blood specimen tested with CDC and PCR showed only positive for P vivax
Treatment Mefloquine, and later Primaquine.
I think for the Knowledge to improve, one has to ,face, challenge regularly,and it should be shared ,otherwise it will fade away
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Diagnose or exclude Pregnancy prior to any clinical management of all women
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Thanks Indragee for the valuable assessments
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