CASE # 1

Mr. Mallory, a 25-year-old student, presents with a 4-day history of high fever
(40C), general malaise, feeling intensely cold and shaking followed by profuse
sweating. He denies any homosexual contacts, unprotected sexual intercourse or
intravenous drug use. He returned from Nigeria 3 weeks ago and was completing his
proguanil with atovaquone malarial prophylaxis treatment. On examination he
looked unwell. His pulse was 98 beats per minutes with a blood pressure of 132/72
mmHg. There are no heart murmurs. There are no enlarged lymph nodes. Blood tests
reveal raised bilirubin with normal liver enzymes, mild anemia and a low platelet
count. Light microscopy of a Giemsa-stained blood smear shows approximately 1%
of red blood cells are infected with Plasmodium parasite. He is kept well hydrated
and treated with oral quinine for 7 days, after which his fever resolves and he starts
to improve.

CASE # 2
Mr. Gill is a 41-year-old African Caribbean, who presents to his GP with increasing
frequency of headaches. He has noticed recent visual disturbances as well. His GP
notes he smokes about 15 cigarettes per day, undertakes very little exercise and
mainly eats fast foods. Urine dipstick was immediately carried out and revealed
significant proteinuria. On questioning, Mr. Gill denies any family history of
diabetes and a random blood glucose test gave a score of 4.7, within the normal
range. However, his resting blood pressure was found to be 210/140, which is
severely elevated and indicative of malignant hypertension. Fundoscopy also
revealed hypertensive changes (silver wiring and cotton wool spots). He is admitted
for immediate treatment. He was given the long-acting calcium-channel blocker,
amlodipine. Two days later, bendroflumethiazide (a thiazide diuretic) was also
added to his management. These two drug classes have been shown to be particularly
effective in African Caribbean with hypertension because of their effect on salt
sensitivity and volume expansion. He is also advised to stop smoking, eat a healthier
salt-restricted diet and do more exercise.