Case Study

Eight-year-old twin boys were brought into the emergency department with complaints of intermittent fevers and lethargy. The boys had not been feeling well for the last 2 weeks. They had recently returned from a trip to Nigeria with their parents. All members of the family had been treated with antimalarial medication before the trip. Neither parent exhibited any of the symptoms of the children. A CBC with differential was ordered as well as a peripheral smear for malarial parasites. The children were slightly anemic, with hematocrits at 33%, and both boys had elevated white counts of around 15.0 X 109/L.

Insights to the Case Study

Both of these young boys had malaria, and ring forms were observed in the thin preparation on the peripheral smear. Plasmodium falciparum was identified. Additionally, they had begun to show slight hemolysis as evidenced by their slightly abnormal hematocrits. Drug-resistant strains of malaria are becoming increasingly common in the world, and cases of malaria are on the rise not only in endemic areas in Africa but also in countries like Peru and Tajikistan, areas where malaria infections were unlikely. When one considers that malaria is still killing 1.1 million individuals a year and still infecting up to a half-billion people a year,10 this health situation is of major impact and significance. Hardest hit are the most vulnerable populations like young children in remote villages who may not have access to vaccine or treatment. Death or life-changing neurological manifestations are common in this population. Many strains of the malaria parasite have also become resistant to chloroquine, once the panacea for malarial protection. Factors such as noncompliance with drug protocol (not taking the drug as long as is necessary) and the indiscriminant use of this drug have led the malarial parasite to adapt to the drug and become resistant to the more common remedies. Our patients were thought to have a drug-resistant strain of malaria, were placed on Fansidar, and made a good recovery.

60 Part I • Basic Hematology Principles

Review Questions _

1. Which of these hemoglobins is an embryonic hemoglobin?

a. Hemoglobin A

b. Hemoglobin Gower c. Hemoglobin F

d. Hemoglobin A 2

2. How many total genes does a person possess for the production of alpha chains?

3. Name one condition that may shift the OD curve to the left.

a. Inheriting a high oxygen affinity hemoglobin b. Metabolic acidosis c. Anemia d. Increased hemoglobin concentration

4. If polychromasia is increased in the peripheral smear, the_should be elevated.

a. white cell count b. red cell count c. reticulocyte count d. basophil count

5. If 2,3-DPG increases, then the hemoglobin molecule will release more oxygen. This is known as a _OD curve.

a. left-shifted b. normal physiological c. right-shifted d. neutral

6. Which of the following statements regarding 2,3-DPG is correct?

a. It catalyzes porphyrin synthesis.

b. It controls hemoglobin affinity for oxygen.

c. It prevents oxidative penetration of hemoglobin.

d. It converts methemoglobin to oxyhemoglobin.

7. When the iron in the hemoglobin molecule is in the ferric (Fe3+) state, hemoglobin is termed a. carboxyhemoglobin.

b. methemoglobin.

c. ferrihemoglobin.

d. sulfhemoglobin.

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