Fever in the tropics – an unpleasant and dangerous companion

In October 2016, Susanne and her boyfriend Heiko travelled to Indonesia and the Philippines for three months to visit special dive spots, broaden their experience as diving instructors and maybe even find a place for their own diving school.

First, they visited friends on the small island of Gili Air and then, with a few stops along the way, travelled to a dream destination for many divers – Raja Ampat in West Papua. After a week's stay there, the journey continued to Negros Island in the Philippines at the end of November.

The journey takes a dramatic turn

After one night with light fever and discomfort, Susanne developed a high fever the following night. She and Heiko were very concerned and went to the nearest hospital in the morning. Blood and urine samples were taken and a malaria test was carried out. Even though this area of the Philippines is not known as a high-risk malaria area, an infection could not be excluded because of the stay in West Papua, which IS a high risk area.

When Heiko collected the results from an external lab, only two words were said to him: "no malaria". Relieved, he passed on this information and the results to the treating doctor at the hospital. As the platelet count in Susanne’s blood was very low, the doctor suspected a dengue virus infection. "There is currently a small epidemic in the area", she said. Susanne was admitted as an inpatient and her symptoms were treated by giving large doses of intravenous fluids. A dengue test was not available at the time.

However, after 4 days of treatment for dengue fever, Susanne's condition continued to worsen. She became more and more short of breath, which is atypical for the usual progression of dengue fever. Another doctor at the hospital became sceptical and looked through Susanne's medical notes carefully. He discovered a test result dated the same day Susanne was admitted which stated: "positive for malaria".

This was a shock for Susanne and Heiko. Where had this test result been for the past 4 days? Local holidays and the health department where results are usually sent first being closed were some of the factors that contributed to the delay in forwarding the malaria positive result. Susanne was transferred to the intensive care unit and needed artificial respiration. She remembers: "I was initially afraid for my life because of the misdiagnosis and the delayed start of treatment."

Heiko called the aqua med diveline. The doctor on duty was firstly able to alleviate their fear, because he knew from experience that a delayed start of treatment is not uncommon in practice. Following internal discussions, Susanne's case was transferred to the doctor's colleague from the aqua med board specialising in tropical medicine. Susanne had the symptoms of a complicated case of falciparum malaria (sometimes also "malaria tropica") which, according to the aqua med doctor, could "most probably be traced back to the wrong treatment, especially the high levels of intravenous fluids." This led to a build-up of water in the lungs (lung oedema) and the shortness of breath.

In addition to other typical symptoms of complicated falciparum malaria and a significant platelet deficiency (thrombocytopaenia), Susanne also had severe anaemia. For this reason, she needed several blood transfusions.

However, after the first transfusion the hospital did not have any more blood of Susanne's blood type in stock. In the area, it is usual to ask friends or relatives if they can donate blood. Since Heiko and Susanne were only passing through they did not know anybody and, unfortunately, hospital staff are not allowed to donate blood. Heiko tried his luck at nearby resorts and diving schools and even contacted a so-called "blood dealer". However, the latter demanded horrendous sums for finding a compatible donor. "A lousy way to benefit from other people's suffering", says Heiko.

Help from an unexpected source

Miraculously, 4 people came to the hospital within a few days wanting to donate blood for Susanne for free. Heiko and Susanne only found out later that a student had heard about their situation from the hospital staff and had launched an appeal on Facebook. Luckily, a compatible donor was found and Susanne received the necessary transfusion. "I was moved to tears by this", Susanne recalls.

The next question to address was what Susanne's further course of treatment should be. As the area where Susanne and Heiko were staying only has a low risk for Malaria, the medical staff do not have much experience in diagnosing and treating it. Also, the medicine best suited for treating Susanne's malaria was not immediately available.

For this reason, the aqua med doctor recommended starting to treat Susanne with the drug Malarone, which was immediately available. It was important not to lose any more time because Susanne was still in a critical condition.

Even though Susanne remembers the staff being "very friendly and warm", the flow of information was still chaotic because the hospital staff did not communicate with each other very well. Susanne and Heiko were therefore pleased that they were able to talk to aqua med on the telephone every day to check whether the treatments were sensible and correct.

Heiko remembers: "You had to be alert at all times. We had lots of different doctors and each one said something different." And Susanne clearly remembers: "One thing was certain – every time I woke up Heiko was at my side taking care of me and everything around us."

On day 2 of the Malarone treatment, the number of parasites in Susanne's blood had decreased significantly. Nevertheless, the haematologist claimed that a more effective drug than Malarone should be used, since "after all, it is only suitable for the prophylaxis." Heiko recalls: "I had the feeling that the doctor was not familiar with Malarone and was afraid to lose face. Conversely, I was afraid that there would be another mistake in Susanne's treatment due to ignorance and a lack of communication. So I checked with the aqua med doctor and was able to hold my own against the haematologist." Although Malarone is not the drug of first choice in treating a severe case of falciparum malaria, a decision was made jointly with a tropical specialist to continue the Malarone treatment for one more day and to wait for the result from the malaria test the next day.

On day 3 of the Malarone treatment, the blood tests showed that the number of parasites had decreased even further, although Susanne still had a fever and still needed artificial respiration. The aqua med doctor and the Filipino tropical specialist decided that Susanne should continue to take the malaria tablets for two more days. This option was only possible because Susanne and Heiko had come prepared with 2 packs of Malarone in their first aid kit.

Further malaria tests over the following days showed a significant drop in parasites in Susanne's blood until it showed none at all. Susanne's breathing, the thrombocytopaenia and the oedema also improved and it was possible to reduce the fever successfully.

The Malarone treatment was stopped after a total of 5 days. Susanne was able to breathe on her own again and was moved from intensive care to a normal ward after 24 hours’ observation. Her blood levels were still being monitored. Although no more parasites could be found in her blood, some electrolytes, the haemoglobin and the thrombocytes were still below the normal range. Susanne was given another blood transfusion to speed up her recovery.

Healthy again – or not?

After 14 days in hospital, Susanne was discharged. She remembers: "I got out of breath just taking the first few steps outside of the hospital." After consulting aqua med, it was decided that Heiko and Susanne should stay at a hotel for a few days to recover. Luckily, Susanne quickly regained her strength and the couple were able to enjoy the rest of their holiday.

However, 2 weeks after coming home there was another shock: Susanne's hair suddenly started falling out in large clumps! This is a delayed effect of a serious febrile disease which causes damage to the hair follicles. Luckily, Susanne’s hair grows quickly and today she has fully recovered.

Heiko and Susanne are planning to go on another long diving trip in October. Maybe this time they will even find the perfect spot for their own diving school...

aqua med doc: "I am very glad that Susanne has completely recovered despite the series of unfortunate circumstances surrounding this severe case of falciparum malaria. I wish Susanne and Heiko the very best for realising their wishes and goals."

Susanne: "After this experience I would advise other divers to ask their diving centre if they have their instructors’ blood types recorded and if they would donate blood in an emergency. My dream is to have a network of travellers who all register the length of their trip, their travel destination and their blood type. Travellers could then help each other in an emergency."

Heiko: "Get advice from a tropical consultant before starting your long-distance journey and get vaccinated. Many health insurance companies [in Germany] even pay the costs. Also, take enough antimalarial medication with you for stand-by treatment when you travel to a malaria area. This way, you are prepared in case of an emergency. If you develop a fever, go to the hospital immediately and get your blood analysed. And the best thing would be to contact aqua med right away."

Heiko und Susanne: "We want to thank aqua med again for their support. We are overwhelmed as we did not expect so much help and such close contact. We will of course tell people about our amazing experience with you and will recommend you! We are very pleased to have discovered you. Thank you so much!"