Dr Nick Read

But they don’t get Malaria in Finland!

Certainly not in the north in late winter, they don’t.   How on earth would a mosquito survive temperatures of -10.  

But this illness was strange.   I know it’s cold here, but shivering that starts when you are sitting in  a warm room; the shaking that won’t stop despite going to bed in a balaclava and polar gear and covering yourself in layers of blankets; that’s not right.  And the headache, not so much a tension that twangs the muscles at the back of your neck or the throbbing nauseous pounding above the temples, but a persistent dull ache that makes your scalp so sensitive you can’t bear anyone to touch it. Then the sweating starts, the covers come off, and you have to get up in the middle of the night and wring out your cotton top and put it on the soapstone stove to dry.  

I’d been ski-ing the previous day.   A lot of falling over, frustration and swearing, but it’s a steep learning curve.  Did I really expect it to be any different on the first day?  I got very cold but lit the stove and put the heater on in the sauna.  Ah, what bliss to sit in the hot moist heat up until the temperature  was unbearable and then run outside, roll in the snow and then pick up handfuls and scrub down before returning to the hot room.   But is that what started it?  Did the exhausting day travelling, the frustrations and cold of learning to ski and the physiologic stresses of the sauna,  light up some lurking infection?  I was already harbouring a crop of cold sores.  Had something else lit up? 

It was still snowing when we awoke, light powder, blown by the wind into sharp edged slopes.  I cleared the veranda, relit the fire and generally tidied up before settling down to write.  Eero had cleared the tracks but it didn’t look inviting enough to go ski-ing.  Then about 11 o’clock, I started to shiver.  It was warm enough in the house, but my body felt cold.  The only thing to do was to get into bed.  The sweating came later that evening.  By the middle of the night my top was soaked.  What is going on.  There is nothing obvious to explain it. 

The next day I felt better enough to go ski-ing again.  I accomplished the push and glide movement and was even able to go downhill without falling over.  I skied down to the hut in the woods – such a special place.  Eero had skidooed a track along the river but the water was coming through in places.  Ice got into the ski clasps.  More delays.  I cooled down, but a simmer in  the sauna followed by a roll in the snow and another spell in the sauna  did the trick. 

It was not a good night.  My headache wouldn’t clear and I had a had to get up several times. In the morning, the shivering returned, followed by sweating.  It was late afternoon by the time the headache and fever receded, but I felt very tired.  So what was going on?  Why did the fevers seem to be coming every other day.  My God; it couldn’t be Malaria, could it?   The periodicity of the illness would fit and I didn’t taking the Malarone all the time in Indochina. I put the thought to the back of my mind and carried on.

I felt better the next morning and the outside temperature had dipped to minus 10.  The skis ran well though I was a little clumsy and fell a few times.  Upon reaching the Russian border, the headache and shivers returned.  I could not get back so phoned for a skidoo.

The paramedics were perplexed but agreed it might be Malaria, but it was Easter, I wasn’t unconscious and they wouldn’t get tests and treatment in north eastern Finland.  They left a bag of Paracetamol and advised me to drink plenty of fluid.  My urine was a very strange colour – fluorescent orange. 

Another sleepless night with headache and fever and I’d had enough.  At Kajaani District Hospital, they plated out a blood film and confirmed the diagnosis, but had to send me further across the country to Oulu University Hospital for treatment.

But Malaria? How?  I came back from South East Asia six weeks ago.  Why did I not get it out there?  Why has it come on now?   And how did I get it when I was taking prophylactics.  The last is easiest to answer.   I had agreed with the practice nurse that I only needed to take Malarone in the high risk zone and since it was not the rainy season, this was Laos.  But I also went to the jungle in Cambodia – down near the coast in the Cardamom Hills.  And there I know the buggers got me!   So was I just too fit and eager for them to get a hold then?  Did they lurk in wait somewhere in my reticulo-endothelial system until that unique Finnish combination of exhaustion and physiological stressors made them sit up.  ‘Hey, guys, it’s the sauna again.  Now’s our chance!’    

What did I know of Malaria before this?   I had learnt about it during the medical students course on Tropical Medicine I took at the London School in Keppel Street, but that’s book learning – absolutely no substitute for the real thing.  And then there are all those films where the hero, crossing Africa, gets Malaria but is saved by the care of the local tribes.  Mind you, travellers in Africa were given a concoction of Senna, Cascara and Julap, called Livingstone’s Rousers , to take for ‘everything’.  This was commonly acknowledged to be the source of the term, ‘The White Man’s Burden’.  But Malaria isn’t a romantic or even a humorous condition.  It’s a multi-system disease.  The little bastards get everywhere.   They invade the blood cells then explode them.  This releases haemoglobin which can clog up the counter current system in the kidneys and encourage the platelets to aggregate in the blood.  These mini-clots can then lodge in small blood vessels particularly in the brain where they can cause oedema, tiredness, psychosis, dementia and coma.   The parasites invade the spleen, the liver the gut, the lungs and everywhere they and their destructive debris lodge they set up inflammation.  So Malaria can result in multi-organ failure.  They used to say that a normal healthy person could stand only five bouts of fever before systems would decompensate, mechanisms run down.  That’s why I became so anxious when on my fourth bout, they kept me waiting in Oulu Triage for 7 hours before seeing a doctor.     

It might seem strange that for one of the most serious diseases, we are still using traditional treatments.   Quinine, in various derivative forms,  is still the classic treatment for Malaria.   It comes from the bark of the Cinchona tree, which grows in the Andes of South America and is named after the Duchess of Cinchon, the wife of the governor of Peru, who became ill with malaria 350 years ago, but who, after drinking a sample of infusion of drink of tree bark in water, made a full recovery.  The Jesuits spread the name of Cinchona’s healing properties throughout the tropical world, but it affected the ears causing slight deafness and tinnitus – the song of the Jesuit.   The Indians used to take quinine as tonic water.  Englishmen still enjoy a G&T on hot summer evenings. 

 Artemesinin comes from a Chinese tree.  In the year 341 AD Mr T Heng published a book on the treatment of medical emergencies in which he recommended the use of the medical herb Qinghao  from annual or sweet Wormwood for the treatment of fevers.  But it wasn’t until 1972, when Chinese scientists extracted an active principle with considerable anti-malarial activity called Qinghaosu.   

In Northern Laos, they use the tuber of the Tarot plant.  They boil up the milky flesh and drink it.  At first, it tastes sweet but when the mouth starts to itch, they know the parasite is gone. 

Each to his own.  They gave me Quinine intravenously then switched it to Artemesininin, which seemed to do the trick.   

Today, the pieces of this puzzle fell into place.  The consultant arrived in some state of animation.  ‘We have the answer.  You have Vivax Malaria.  Plasmodium vivax can have an incubation period that can vary from 17 days up to as long as a year.   It is a milder disease than falciparum but cannot be completely eradicated.  It can lurk in the liver for years, though apart from a tendency to tiredness,  does not cause undue debility and any flare ups can be promptly treated.   The enlarged spleen is a bit of a risk but should go down.

Bloody ‘ell!