Correspondence
Case 4-2009: A Pregnant Woman with Fever after a Trip to Africa
N Engl J Med 2009; 360:2481-2482June 4, 2009
- Article
To the Editor:
Duff et al. (Jan. 29 issue)1 report a case of a 39-year-old pregnant woman with a fever after two trips to Africa less than a year apart. The authors state that the patient “took mefloquine daily during each trip and for 3 weeks after returning from each trip.” It is important that travelers take medications for malaria prophylaxis properly.
Prophylactic administration of mefloquine should begin at least 1 week before arrival in a area where malaria is endemic. Subsequent weekly doses should be taken regularly, always on the same day of each week, preferably after a full meal. To reduce the risk of malaria after leaving an endemic area, prophylaxis should be continued for 4 additional weeks to ensure suppressive blood levels of the drug when merozoites emerge from the liver.
1 ReferencesMarc Itskowitz, M.D.
Allegheny General Hospital, Pittsburgh, PA 15212
mitskowi@wpahs.org 1
Case Records of the Massachusetts General Hospital (Case 4-2009). N Engl J Med 2009;360:508-516
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To the Editor:
Duff et al. report the case of a pregnant woman with fever and hepatic dysfunction, which developed 3 months after the most recent of two visits to East Africa, implying a disease with a long incubation period. A differential diagnosis is offered, but several important disease possibilities are omitted. Although intestinal parasites were ruled out because of a negative stool test for ova and parasites, tissue parasites, including visceral leishmaniasis1 and toxocariasis,2 remained possibilities. There was no discussion of the elevated eosinophil count. Schistosomiasis was apparently ruled out because of the negative stool analysis and antibody test. However, eggs may be excreted sporadically or in small numbers, making stool analysis less useful. A negative schistosoma antibody is reported, but the sensitivity of the test of enzyme immuno units for species other than Schistosoma mansoni is reduced.3 Reference is made to hepatitis A, B, and C, and the associated serologic tests were negative. However, there is no reference to hepatitis E, which is found in East Africa and represents a special risk to pregnant women.4
4 ReferencesJeffrey G. Jones, M.D., M.P.H.
St. Francis Traveler's Health Center, Indianapolis, IN 46203
jjones3054@aol.com 1
Ryan JR ,Mbui J ,Rashid JR , et al. Spatial clustering and epidemiological aspects of visceral leishmaniasis in two endemic villages, Baringo District, Kenya. Am J Trop Med Hyg 2006;74:308-317
Web of Science | Medline2
Despommier D . Toxocariasis: clinical aspects, epidemiology, medical ecology, and molecular aspects. Clin Microbiol Rev 2003;16:265-272
CrossRef | Web of Science | Medline3
Tsang VC ,Wilkins PP . Immunodiagnosis of schistosomiasis. Immunol Invest 1997;26:175-188
CrossRef | Web of Science | Medline4
Mushahwar IK . Hepatitis E virus: molecular virology, clinical features, diagnosis, transmission, epidemiology, and prevention. J Med Virol 2008;80:646-658
CrossRef | Web of Science | Medline
To the Editor:
Case 4-2009 is a tragic one in many respects: A woman who was unsuccessfully treated for infertility terminated her first, long-sought natural pregnancy after cytomegalovirus (CMV) was detected in amniotic fluid at 21 weeks' gestation. The article clearly shows how difficult diagnosis and counseling for CMV infection in pregnancy can be when experience is limited. The discussants report that when the patient knew the results of amniocentesis, “she believed she could not cope with an infant who was likely to be very sick.” Since ultrasonography of the infected fetus was apparently normal, I question which additional data the clinicians used as the basis for such a negative prognosis. Altogether, the impression is that this woman did not receive tailored counseling. In addition, neither administration of hyperimmune globulin in the case of positive results on amniocentesis nor repetition of amniocentesis in case of negative results was recommended. Finally, it is disconcerting that after presenting such a tragic case, the discussants did not include women undergoing assisted procreation procedures among potential target groups for CMV testing. Congenital CMV remains a largely ignored problem.
Maria Grazia Revello, M.D.
Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
mg.revello@smatteo. pv. it Author/Editor Response
Itskowitz correctly notes that the patient did not take her malarial prophylaxis for a full 4 weeks after returning from the trip to Africa. For this reason, and because antimalarial prophylaxis is not 100% effective even when taken correctly, malaria was strongly considered in the differential diagnosis. The negative malarial smears were compelling evidence against this infection.
Jones correctly notes that the patient might have had several different parasitic diseases and that the negative examination of the stool for ova and parasites did not absolutely exclude all such diseases. Moreover, he also notes that hepatitis E should have been a diagnostic consideration. Although multiple parasitic diseases and all forms of viral hepatitis were considered by the clinicians caring for this patient, limited editorial space prevented a complete discussion of all possible disorders that might have caused her symptoms.
Finally, Revello expresses concern about the counseling the patient received. In fact, she received detailed counseling about the potential dangers of primary versus recurrent CMV infection and about the limitations of ultrasonography in delineating the full extent of fetal injury. After considerable anguish, she elected to have her pregnancy terminated. Despite the reassuring results on ultrasonography, pathological examination of the fetus showed evidence of severe injury to major organs, notably the lung and liver.
We agree with Revello's statement that women undergoing assisted reproductive procedures are appropriate candidates for CMV screening. We also agree that anti-CMV hyperimmune globulin for the treatment of congenital CMV infection is still experimental. Nevertheless, given the promising report by Nigro et al.,1 the use of this agent merits further consideration.
1 ReferencesPatrick Duff, M.D.
University of Florida, Gainesville, FL 32610-0294William H. Barth, Jr., M.D.
Miriam D. Post, M.D.
Massachusetts General Hospital, Boston, MA 021141
Nigro G ,Adler SP ,LaTorre R , et al. Passive immunization during pregnancy for congenital cytomegalovirus infection. N Engl J Med 2005;353:1350-1362
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