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The not-so-unlikely diagnosis

01 September 2007

Three months after returning to the UK after a holiday in Gambia, Miss N, a 27-year-old care assistant, telephoned her GP practice for advice and spoke to Dr T. She told him that she was feeling generally unwell and slightly feverish and had noted that her urine was unusually dark. Dr T thought that she was probably suffering from ’flu, with some dehydration, and advised Miss N to take paracetamol and plenty of fluids. In taking her history, he did not ask her whether she had travelled abroad in the last year, nor did he review her notes, which recorded a visit for vaccination against tropical diseases four months earlier.

Two days later, Miss N telephoned the surgery again to report that she was feeling much worse. She had been suffering chills and fever, followed by profuse sweating, and was also experiencing gastric symptoms in the form of diarrhoea and vomiting. This time she spoke to Dr H, who considered that the most likely diagnosis was viral gastroenteritis. She advised Miss N to take plenty of fluids and to contact the surgery again if her symptoms had not subsided in 48 hours.

Miss N was rushed to hospital after collapsing at home two days after this phone call. She died soon after admission and a postmortem examination confirmed the cause of death as Plasmodium falciparum malaria.

Subsequently, a claim was brought against both Dr T and Dr H on behalf of Miss N’s 6- year-old son, alleging negligence in failing to consider malaria as a cause of Miss N’s symptoms.

Expert opinion

We asked a GP expert to review the case and he concluded that both Dr T and Dr H had failed to deliver an acceptable standard of care. They both had access to Miss N’s notes, yet neither had appeared to review the most recent entries, in which they would have learned that she had recently travelled to a tropical country. Furthermore, he considered that it should be standard practice, when taking a history from a patient presenting with Miss N’s symptoms, to include a question about any travel abroad in the previous 12 months.

He was especially critical of Dr H, however, for not taking Miss N’s complaint of fever more seriously. Although viral gastroenteritis is often accompanied by a lowgrade fever, the chills and sweating Miss N described should have alerted Dr H to the possibility that she had contracted a more serious infectious disease.

Moreover, as she had already been ill for two days, and diarrhoea had only just developed, he felt that viral gastroenteritis was not the most obvious diagnosis to account for this history.

On the basis of this opinion, the case was settled out of court for a substantial sum.

Learning points

  • According to WHO estimates, more than 30,000 international travellers a year fall ill with malaria.
  • Plasmodium falciparum malaria can be fatal, and is Chloroquine-resistant in regions where it is endemic.
  • The onset of malaria can be delayed, especially when the patient has been taking prophylaxis.
  • The early signs and symptoms of malaria are nonspecific, so asking patients presenting with ’flu-like symptoms about travel they have undertaken in the previous 12 months is key to making the diagnosis and should be included in the history-taking.
  • WHO advises the following, “Fever occurring in a traveller one week or more after entering a malaria risk area, and up to three months after departure, is a medical emergency that should be investigated urgently. Prompt diagnosis and correct treatment of malaria can mean the difference between life and death.”
    www.who.int/malaria/malariaandtravellers.html
  • It is a matter of good practice to review the patient’s notes for each consultation.
  • If a patient is not improving, the diagnosis should be reviewed and further investigations initiated.

Further information

For up-to-date guidance on the diagnosis and management of malaria, see Griffith, KS et al, Treatment of Malaria in the United States: A Systematic Review, JAMA 297 (20): 2264–77 (2007).
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