Malaria, Typhoid, or Both?

All four of us have had malaria now– mild cases for everyone, fortunately, but I can assure you that it’s no fun. It’s particularly vexing for our family because we use an awful lot of precious Nutella and jam to get the kids to take their awful-tasting Mefloquine every week, and we aren’t the only family taking prophylaxis faithfully to get malaria this year– several other folks here on campus who take medications ostensibly to prevent us from ever getting it have had to settle for “at least we didn’t need to be admitted for it”.

Sadly, children in the community without the luxury of living right next to the hospital or taking prophylaxis haven’t been as fortunate. The rains seemed to have started a little earlier this year, and whether the parasite itself is getting more virulent or the mosquitoes are biting more, we are seeing more cases requiring transfusions and deaths several times a week in young children.

With very little data to work with besides our own overflowing wards (and similar stories from other clinics and hospital all over town), we can only conclude that transmission of the parasite is more frequent and the best we can do is test as early as possible and treat as quickly as possible.

Fortunately, malaria is one of the few diagnoses we can reliably make in the hospital because you can see it on a blood smear. The lab tests we can order all fit nicely on a half-sheet of paper, and half of these we rarely order anyway:


However, malaria shares a number of clinical features with typhoid– both cause fevers, headache, dizziness, abdominal pains, vomiting, joint and muscle aches. The main differences when taking a history are that typhoid tends to cause constipation while malaria can sometimes cause more diarrhea and malaria tends to be much faster in onset– but that’s about it, at least in the first week of illness.

You can order labs for typhoid, though– the Widal test, an old serologic test that measures antibodies to the Salmonella typhi bacteria. Unfortunately, this test can’t distinguish between current infection, previous infection, or successful immunization, so in a population where typhoid is quite common there are quite a few false positives. This hasn’t seemed to slow down the test’s popularity, as it is still used quite a bit because it is cheap and quick.

When discussing patients with our clinical officers and nurses, we often have to remind them of this false-positive problem and ask if there are really enough clinical symptoms present to convincingly make a diagnosis of malaria and typhoid. Many of our patients are sick enough to justify using antibiotics to cover typhoid in addition to antiparasitic drugs for malaria, but many aren’t. We certainly don’t want to expose our patients to potential side effects or create antibiotic resistance in an area where few drugs are available. We also don’t want to waste precious resources since the drugs we do get are imported and patients pay more for each drug we order! Thus, in the midst of our current wet season with malaria popping up everywhere and causing more severe cases than usual, I prefer not to even use the Widal test unless I have a really good story that makes me think my patient has typhoid instead. (And even then, I’ll still check for malaria anyway.)

So I when started feeling achy and fatigued, I of course dilly-dallied for a day or two before finally getting tested– and I didn’t bother ordered a Widal, since I was vaccinated. My smear came back positive and I started on treatment. I was especially thankful that we had several other doctors at the hospital who could take over while I was sick– when we came for our survey trip, there were only two doctors working full-time and when one of them got sick or went on vacation, managing 40-50 patients a day was just up to one person!

I finished my three days of medication and woke up in the middle of the night, unable to go back to sleep because it hurt to roll over. I took ibuprofen and paracetamol but still felt awful and got caught up on a lot of podcasts as I gained a new appreciation for why the pediatric ward was always full of shrieking children. I spoke to our wise medical director, Graham, who recommended that with persistent symptoms, I should probably just start treatment for typhoid.

After a day of mostly sleeping and taking Amoxicillin, I felt great. I got up, jumped right back in on the wards, and didn’t take another dose of pain meds. I still don’t know if my symptoms were caused by typhoid, malaria, both, or neither– perhaps I had a virus that got better at the same time I started taking the antibiotic and just happened to have a positive malaria smear– but who knows? Here, we just have to do the best we can with what we have and continue to train enough medical professionals to assess and treat people with malaria quickly enough that they don’t require transfusions or get sick enough to die.

I still don’t order the Widal, though. And I’m trying to teach our staff to be more judicious with it, too!

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