Case history from the New England Journal of Medicine (Vol. 346, No. 26, June 27, 2002)

The movie clip below accompanies case history 20-2002 from the Case Records of the Massachusetts General Hospital, New England Journal of Medicine (http://www.nejm.org).  The movie clip shows motile Trypanosoma brucei rhodesiense organisms in a wet preparation of the patient’s blood.  Below is a brief summary of the case.

The patient is a 37-year-old man admitted because of fever and an inflamed foot.  He had spent the previous 3 months touring South America, followed by southern and eastern Africa.  Ten days before admission, he visited game reserves in Tanzania, where he sustained multiple tsetse fly bites. He proceeded to Kathmandu and shortly after arrival, 4 days before admission, he developed pain in the left foot and high fever.  The next day, he noted progressive swelling on the dorsum of the foot, and he was evaluated at a local clinic.  A malaria smear was negative and he was prescribed cefalexin.  He continued to have intermittent high fever (to 41°C) and developed vomiting, headache, myalgia, and a diffuse rash.  A repeat malaria smear was negative, but white cell count was 4000 per mm3 with 10% band forms.  He returned to the United States and entered the hospital.

The patient is a construction worker and outdoorsman, previously in excellent health.  He did not obtain pretravel immunization for typhoid or chemoprophylaxis for malaria, but his hepatitis A and B immunizations were up to date.  He had no known allergies, and was taking no medications.

His temperature was 39.4°C, pulse 85, blood pressure 120/60 mm Hg.  He had a blanching macular rash over his entire trunk.  Tender 2 cm axillary and left femoral lymph nodes were palpated.  His lungs and heart were normal.  His liver descended 3 cm below the costal margin and his spleen tip was palpated.  A shallow ulceration was present on the left instep, encircled by bullae at the margin, and was surrounded by induration and violaceous erythema.  Diameter of the foot lesion was 5 cm.  He was mentally intact and his neurologic examination was normal.

The patient's hematocrit was 39.3 and the white cell count was 2600 per mm3, with 58% neutrophils, 24% band forms, 8% lymphocytes, and 10% atypical lymphocytes.  Prothrombin time was slightly elevated at 14.5 seconds, and his platelet count was 45,000 per mm3.  His creatinine was 2.0 mg/dl.  Sodium was 125 mmol/l and other electrolytes were within normal limits.  Bilirubin was 5.6 mg/dl, with a conjugated bilirubin of 4.9.  The aspartate aminotransferase was 528 U, lactate dehydrogenase 1566 U and alkaline phosphatase 256 U/liter.  An electrocardiogram was unremarkable, and chest radiographs showed patchy opacities in the left lower lobe consistent with atelectasis.  Examination of a wet preparation of blood is shown.

Video clip