12-06-2008, 01:00 PM
A 63-year-old woman is evaluated because of increasing nausea, malaise, and decreased appetite. The patient has just returned from her second trip to rural areas of southern India, and her symptoms developed 2 days before returning to the United States. She developed Plasmodium falciparum malaria following her first trip to India, when she had not taken antimalarial prophylaxis. She took mefloquine for this current trip. None of her traveling companions have become ill.
On physical examination, she is awake and oriented but is in moderate distress because of nausea and malaise. Temperature is 38 °C (100.4 °F), pulse rate is 116/min and regular, respiration rate is 28/min, and blood pressure is 98/60 mm Hg. Crackles are heard at the pulmonary bases bilaterally, and a grade 2/6 systolic murmur is auscultated. The abdomen is obese with decreased bowel sounds and moderate right upper quadrant tenderness. The liver is palpated 4 cm below the right costal margin and is very tender. There are no other masses or organomegaly. The extremities and neurologic examination are normal.
Laboratory Studies
Hemoglobin
10.9 g/dL (109 g/L)
Hematocrit
31%
Leukocyte count
6100/μL (6.1 × 109/L)
Platelet count
98,000/μL (98 × 109/L)
Blood urea nitrogen
24 mg/dL (8.57 mmol/L)
Serum creatinine
1.9 mg/dL (168 µmol/L)
Serum electrolytes
Normal
Serum aspartate aminotransferase
6200 U/L
Serum alanine aminotransferase
8500 U/L
Serum alkaline phosphatase
720 U/L
Serum total bilirubin
6.9 mg/dL (117.99 µmol/L)
Plain radiographs of the abdomen are normal. The patient is hospitalized for rehydration. She becomes increasingly icteric, her condition deteriorates rapidly, and she develops multi-organ system failure.
Which of the following prophylactic measures may have prevented this patient's illness if given before her current trip?
A Malarial prophylaxis with a drug other than mefloquine
B Hepatitis A immunization
C Hepatitis B immunization
D Typhoid immunization
On physical examination, she is awake and oriented but is in moderate distress because of nausea and malaise. Temperature is 38 °C (100.4 °F), pulse rate is 116/min and regular, respiration rate is 28/min, and blood pressure is 98/60 mm Hg. Crackles are heard at the pulmonary bases bilaterally, and a grade 2/6 systolic murmur is auscultated. The abdomen is obese with decreased bowel sounds and moderate right upper quadrant tenderness. The liver is palpated 4 cm below the right costal margin and is very tender. There are no other masses or organomegaly. The extremities and neurologic examination are normal.
Laboratory Studies
Hemoglobin
10.9 g/dL (109 g/L)
Hematocrit
31%
Leukocyte count
6100/μL (6.1 × 109/L)
Platelet count
98,000/μL (98 × 109/L)
Blood urea nitrogen
24 mg/dL (8.57 mmol/L)
Serum creatinine
1.9 mg/dL (168 µmol/L)
Serum electrolytes
Normal
Serum aspartate aminotransferase
6200 U/L
Serum alanine aminotransferase
8500 U/L
Serum alkaline phosphatase
720 U/L
Serum total bilirubin
6.9 mg/dL (117.99 µmol/L)
Plain radiographs of the abdomen are normal. The patient is hospitalized for rehydration. She becomes increasingly icteric, her condition deteriorates rapidly, and she develops multi-organ system failure.
Which of the following prophylactic measures may have prevented this patient's illness if given before her current trip?
A Malarial prophylaxis with a drug other than mefloquine
B Hepatitis A immunization
C Hepatitis B immunization
D Typhoid immunization