Tunde had taken two full courses of antimalarials for a fever that would not break. At Mascot Healthcare, a malaria rapid test came back negative. A Widal test confirmed typhoid fever — the actual cause of 12 days of misery. Ciprofloxacin cleared it within a week.
Mechanic, Mushin. Presented with 12-day history of fever, headache, abdominal pain, and malaise — had completed two courses of artemether-lumefantrine (AL) at home based on pharmacy advice. Malaria RDT at Mascot Healthcare: negative. Widal test: O titre 1:320, H titre 1:160. Typhoid fever confirmed.
Malaria RDT + Widal TestTunde's fever had begun on a Monday — the kind of fever he had had before with malaria. He knew the pattern: go to the pharmacy, collect artemether-lumefantrine (AL), complete the course. He did. Four days later, the fever was back. He returned to the pharmacy. "It's a resistant strain," the pharmacist had said. Second course of AL prescribed. Five days after completing the second course, the fever had not resolved. His abdomen had begun to ache.
He came to Mascot Healthcare on Day 12. The doctor took the history carefully: 12 days of fever, abdominal pain, headache, anorexia — and two courses of artemether that had not worked. "The first thing we need to do," the doctor said, "is confirm whether this is actually malaria — because two courses of correct antimalarial treatment should have cleared it."
The malaria RDT was performed: negative. The blood film confirmed: no malaria parasites. "You don't have malaria," the doctor said. "You probably never had it. We need to test for typhoid." The Widal test result returned the same day: O titre 1:320 — strongly positive for Salmonella typhi.
Fever in Lagos has a broad differential. Malaria and typhoid fever are the two most common causes — and they present identically at the outset. Treating one while the other is the actual diagnosis is extremely common in Nigeria without laboratory confirmation.
Detects malaria parasite antigens in blood within 15 minutes. More accurate than clinical diagnosis. Negative = malaria extremely unlikely.
Microscopic examination — confirms RDT result and identifies the malaria species. Gold standard for malaria diagnosis.
Detects antibodies to Salmonella typhi antigens. O titre ≥ 1:160 in the clinical context is significant. Tunde's: O 1:320 — strongly positive.
The gold standard for typhoid — isolates Salmonella typhi from blood in the first 1–2 weeks of illness. More definitive than Widal but takes 48–72 hours.
Typhoid typically causes leucopenia (low white cell count) with relative lymphocytosis — a pattern that distinguishes it from bacterial sepsis.
In Nigeria, fever is commonly treated as malaria without laboratory confirmation — a practice that leads to massive overuse of antimalarials and significant delays in diagnosing typhoid, bacterial sepsis, viral hepatitis, and other treatable conditions. Two full courses of artemether-lumefantrine have no effect on typhoid fever.
Untreated typhoid fever progresses to serious complications: intestinal perforation, haemorrhage, and septicaemia — which are surgical emergencies with high mortality. Tunde's 12-day delay had allowed the infection to become well established. Prompt antibiotic treatment was needed immediately.
A 14-day course of prescribed medication was given — the standard treatment for uncomplicated typhoid fever in Nigeria (the choice guided by local sensitivity patterns; culture and sensitivity was sent to confirm). Full blood count: WBC 3.2 × 10⁹/L — leucopenia, consistent with typhoid.
Supportive management: oral rehydration (typhoid causes significant fluid losses through fever and reduced intake); a painkiller for fever; soft diet; rest. Tunde was told: fever typically resolves within 5–7 days of starting treatment; improvement should be noticeable within 48–72 hours.
At day 4 of treatment: fever resolved. At day 7: appetite returned, abdominal pain resolved. Blood culture (returned at 72 hours): Salmonella typhi isolated — confirming the diagnosis.
Malaria RDT/film: negative. Widal O 1:320. Blood culture: Salmonella typhi. FBC: leucopenia. Typhoid fever confirmed.
A 14-day course of prescribed medication; ORS; a painkiller for fever; soft diet; food hygiene counselling; water purification advice.
Fever resolved Day 4. Full recovery Day 10. Repeat Widal at 4 weeks: O titre 1:80 (falling — appropriate). No relapse.
Tunde recovered fully within 10 days of correct diagnosis and treatment. He had been ill for 12 days with wrong treatment before the correct diagnosis was made. He now asks for a malaria test before taking any antimalarial.
Fever in Lagos is not always malaria. Typhoid, hepatitis, pneumonia, and urinary tract infection can all present with fever — and none of them respond to antimalarials. A malaria test before treatment takes 15 minutes and prevents weeks of wrong treatment.
Two completed courses of artemether-lumefantrine that do not clear a fever mean the fever is not malaria. This should always prompt testing for alternative diagnoses — not a third course of antimalarials.
Fever that didn't clear with malaria treatment is probably not malaria. A RDT takes 15 minutes and tells you the truth. Test before you treat.
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