MRCP2-2947

MRCP2-2947

A 28 year old Caucasian man has just returned from a 10 week trip to Thailand where he was backpacking. He had not consulted a travel clinic for immunisations and had taken no malaria prophylaxis. During his trip he stayed in budget hostels and ate street food. For the last few days of his trip he felt very unwell. He developed fevers, diarrhoea and vomiting, however this was improving and he had been feeling much better when he arrived home in the UK.

He has been home for 48 hours. Today he felt very much worse and presented to A and E.

On admission:
Temperature: 38.9C
Blood pressure: 95/62mmHg
Pulse: 82 / min
Respiratory rate: 22 / min
Oxygen saturations: 98% on room air.

His initial investigations show:

Hb 12.5 g/dl
Platelets 80 * 109/l
WBC 4.2 * 109/l
Neutrophils 2.8 * 109/l
Lymphocytes 1.2 * 109/l

Na+ 142 mmol/l
K+ 3.9 mmol/l
Bicarbonate 22 mmol/l
Urea 8.2 mmol/l
Creatinine 98 mol/l

Bilirubin 21 umol/l
ALP 98 u/l
ALT 62 u/l
γGT 28 u/l
Albumin 38 g/l

Following discussion with the ID consultant on call, he is isolated while a blood sample is sent to Public Health England’s imported fever service. He received empirical therapy for Malaria with Artesunate and for sepsis with Ceftriaxone and Metronidazole, however he rapidly deteriorated and died within 48 hours of admission. Following discussion with Public Health England, who confirm that there was no evidence of a nosocomially transmitted Viral Haemorrhagic Fever, he has a post mortem examination which reveals evidence of severe dehydration and electrolyte imbalance.

What could have been done to prevent his death?