Plasmodium falciparum puzzle challenge

Patient's history :

A 56-year old male had recent travel history to West Africa where he was involved with a group donating various foods and supplies to areas hard hit with the Ebola epidemic. He was there for approximately one month and had returned 2 weeks prior to the symptoms occurring.

After he was came back for Africa, he was in obvious distress, confused and lethargic. He was pallor and was sweating profusely. His responses to questions were incoherent and at times he would would not respond at all. His response to painful stimuli was poor.

He was febrile with a body temperature of 38 degrees celsius. Blood tests were significant for elevated liver enzymes; moderate thrombocytopenia; moderate anemia (8.6 g/dL); and a 2.4% reticulocyte count. He also had a urinalysis performed in which the color of the urine was described as dark amber with 20-30 RBCs; 3+ hemoglobin and 3+ protein. Blood cultures were negative.

Geimsa stained preparations were requested and made on freshly collected blood at the bed side for thick and thin smears. The smears were reviewed by the Pathologist. The diagnosis was made based on the smears seen below:

Picture 1

Picture 2

• What significant form is seen in photo #1?
• What significant form is seen in photo #2?
• What would you expect to see on the stained thick smear?
• What is the identification of this parasite?
• Is this a mild, moderate, or severe infection?
• Why is it important to make a rapidly correct diagnosis in this patient given the presentation and the travel history?

IDEA 1 :

Gametocyte in photo 1
Ring form in photo 2
Ring form trophozoites in thick smear
Plasmodium falciparum
Severe infection
This is the most fatal form of malaria, and patient cells are lysing. Treatment should begin as soon as possible.

IDEA 2 :
Photo 1 is gametocyte form
Photo 2 is ring form
You would see both of these forms in thick smear
This is plasmodium falciparum
The infection is severe
Plasmodium falciparum is the most severe and potentially deadly of the malarial parasites, and treatment must begin as soon as possible. This patient’s red cells are lysed.

IDEA 3 :
Photo # 1 Banana-shaped gametocyte
Photo # 2 Trophozoites and applique forms
Plasmodium falciparum
Severe infection with Cerebral malarie via cytoadherence and sequestration
Correct diagnosis is important to initiate the correct treatment immediately–high mortality rate with falciparum

IDEA 4 :
Gametocyte of plasmodium falciparum in photo 1;
Ring stage of trophozoites in photo 2;
It is moderate to severe infection;
Plasmodium falciparum is the type of malaria that most often causes severe and life-threatening malaria. According to the patient’ symptoms, such as high fever, mental confusion and dark ember urine, plus travel history, drop blood should be examined immediately to help diagnosis.

IDEA 5 :
Photo 1 shows the typical banana-shaped gametocyt
Photo 2 shows typical trophozoietes for pl. Falciparum
In the thick smear I expect a great amount of thropozoietes like stars in the sky and some gametocytes
It’s a severe infection with Plasmodium falciparum
The importance of a quick diagnosis in this case is dual: 1) for the malaria diagnosis it is important because it is very important to treat it as soon as possible because of the high mortality; 2) in this specific case it is also important to rule out Ebola infection

IDEA 6 :
1- Photo #1 is mature macro gametocyte Plasmodium falciparum
2- photo #2 is trophozoites of single and double chromatin dots and ring of marginal form
3- Deformed of gametocytes and rings or young trophozoites without normal RBC and WBC
4- Diagnosis is Plasmodium falciparum
5- That would be a wild form according number RBC’s involved
6- This Malaria P.falciparum could be important because cause death of patient and may be resistant to treatment of anti-malaria drugs.

IDEA 7 :
The patient has the ring forms (trophozoits)of falciparum species and the gametocyte stage giving the correct diagnosis of malaria infection.