On the road…again!
Afghanistan to Zambia
Chronicles of a Footloose Forester
By Dick Pellek
The Quirkiness of Malaria
Malaria is a serious scourge in the tropical countries of the world. According to the World Health Organization, in 2010 there were 216 million episodes of malaria resulting in 655,000 deaths. The Peace Corps doctors thus made sure that we volunteers were aware of the perils of malaria, as we began making final preparations for departure to our countries of assignment. In our case, part of that preparation was taking the prescribed chloroquine phosphate tablets a couple of weeks before setting off for Pakistan.
All went well for the Footloose Forester during his tour in Pakistan. No malaria, despite having to sleep outside much of the time and very often without a mosquito net. In fact, with his prolonged residence in malarial infected areas in subsequent years, he looked back on the fact that he had been taking anti-malarial prophylaxis medicines more or less continuously for about 12 years.
Malaria has more than one strain; indeed there are at least four major forms of the disease, caused by the transmission of one of the Plasmodium parasite species into the bloodstream of its victims. The dreaded Plasmodium falciparum parasite can attack the brain and kills by inducing a high fever, among other symptoms. The Footloose Forester knew a Peace Corps Director in Haiti who died from the P. falciparum form of malaria.
The medications required to prevent the clinical symptoms of various strains of malaria are different; the prophylactic treatments are specific to the tropical regions where the various species of plasmodia are thought to be prevalent. Thus, the prophylaxis treatment for malaria caused by Plasmodium falciparum is different from the malaria caused by the far more widespread Plasmodium vivex. For most of the years that the Footloose Forester took malarial prophylaxes to mask the symptoms of malaria, he took chloroquine phosphate to ward off P. vivex symptoms.
Malaria transmitting Anopheles mosquito
Somewhere along the way, the medication was changed from chloroquine phosphate to the formulation known as Primaquine. He took that in Viet Nam and had no problems during nearly three years in country. Finally, his prescription was changed to another formulation known as mefloquine. That was when he was scheduled to spend several months in Indonesia. And that is where the Footloose Forester was infected with malaria.
When he showed up at the Kaiser Permanente Hospital in Honolulu some 10 months after returning from Indonesia, the medical staff in the emergency room checked his symptoms and took some blood samples; but dismissed him when they could not find any medical indications of malaria in his blood. They were not the only ones who did not diagnose malaria right off the bat. The previous day, he had checked in with the clinic at the University of Hawaii, and described his recent bouts of chills and fever. The physician on staff was an Indian woman who should have known the symptoms, but she did not make any recommendations other than bed rest. Indeed she did inquire about the kind of malarial prophylaxis he was taking, but failed to make any links with the symptoms he displayed. He went home to spend the rest of the day and night experiencing chills and fever.
After the first trip to Kaiser Permanente Hospital, he was back in the emergency room less than 24 hours later. Honolulu had experienced a major traffic accident at that time and the hospital was short of beds, so the hospital staffers were apologetic when they offered him a wheelchair to sit in, rather than wait out the expected delay before they attended to him. Eventually, they came by to take and analyze additional blood samples. It was hours before they came back with the results. The Footloose Forester remembers telling them that he did not mind the long wait; he was in a semi-coma while sitting there in the wheelchair.
The doctor who showed up next had a big smile on his face and a magazine in his hand. On the cover of the medical journal was a large picture of an Anopheles mosquito, with the caption “Return of the bad penny”; it was the vector of the Plasmodium vivex that had slapped down the Footloose Forester. Once it was properly diagnosed, the Viet Nam War military physician packed his feverish body in ice, over a rubber blanket.
Why is this chronicle only now being written? Perhaps it was because the Footloose Forester recently spent a night at home with simultaneous chills and fever, combined with a persistent headache centered in the greater occipital nerve. The headache malady was probably of a different origin, but he recalls that other people he knew who had contracted malaria claimed that bouts of chills and fewer returned infrequently, even years after they had been “cured” of malaria. One man who contracted malaria twice also exhibited jaundice, and it was the jaundice that tipped him off about a pending attack.
Prior to his going to Indonesia to conduct research in tropical forests, the medical authorities at the University of Hawaii did the requisite cross-checking to insure that the malarial prophylactic was the proper one for their patient; and for the region. The Footloose Forester completed his tour without clinical symptoms, except for the fact that he lost 33 pounds on a restricted diet in the jungle. His neighbor in Honolulu; however, remarked that he seemed to have gained back the weight he had lost—just a few days before he came down with the symptoms of malaria. And that is the whole point of this chronicle about the quirkiness of malaria. When we had that little chat while standing in front of her house, the Footloose Forester replied that he had regained only three pounds of the 33 pounds he had lost. Since it was ten months after he had returned from Indonesia, he was curious why he had not regained his previous weight. The long time-lapse also may have influenced the doctors who may have thought that the timing was far beyond the stage when symptoms of malaria would show up.