Case Presentation:
A 49‐year‐old African American woman presented to the emergency room (ER) with a 3‐day history of high‐grade fevers, chills, and generalized muscie aches after returning from a 3‐week trip to Nigeria without malaria prophylaxis. On admission her temperature was 39°C, heart rate was 99 beats per minute, and blood pressure (BP) was 100/50 mm Hg. On exam she had mild conjunctival pallor. Laboratory tests revealed mild microcytic anemia (HB 11.1 g, MCV 74 fL), WBC of 5600/μL with 46% bands, and severe thrombocytopenia (platelets of 27,000/mcL). Total bilirubin was 1.5 mg/dL, and direct was 0.6 mg/dL. After obtaining blood cultures and malaria smears, broad‐spectrum antibiotics, doxycycline, and quinine were started in the ER. However, a few hours later, she became hypotensive without response to intravenous fluid resuscitation and was transferred to the medical intensive care unit (ICU). Four hours later repeat hemoglobin was 8 g/dL. A peripheral thick film smear showed ring forms of Plasmodium falciparum with 5.2% parasitemia. She was started on vasopressors and transfused with packed red blood cells. The Centers for Disease Control (CDC) was contacted, and IV artesunate was delivered from Atlanta, Georgia, and started the same evening. The patient's status improved, vasopressors were discontinued on the third day of the MICU stay, and blood cultures remained negative. By the fourth hospital day, the peripheral smears became completely clear of malaria parasites, and she was discharged home with oral doxycycline to complete the treatment.
Discussion:
Severe malaria is almost exclusively caused by Plasmodium falciparum. The World Health Organization has established clinical and laboratory criteria for severe P. falciparum malaria. It constitutes a medical emergency because of its fulminant course if left untreated. Circulatory collapse (algid malaria) is a rare (0.37%) complication of malaria that can be rapidly fatal and has a mortality of 15%–20% even in the best centers. The pathophysiology of circulatory shock has not been clearly elucidated but is believed to a combination of release of tumor necrosis factor (TNF), impaired microcirculation, and metabolic acidosis. It is often associated with gram‐negative sepsis, and thus blood cultures and broad‐spectrum antibiotics are essential. The cornerstone of management is the prompt recognition of malaria, rapid initiation of combination antimalarial treatment, and early transfer to an ICU for necessary supportive care. Parenteral artesunate reduces mortality in severe P. falciparum malaria when compared with quinine use and can be obtained from the CDC Malaria branch.
Conclusions:
Severe malaria is a life‐threatening emergency and requires parenteral antimalarial treatment and aggressive supportive care in an ICU setting.
Author Disclosure:
C. Ezeokoli, none; M. Papireddy, none; T. Almouradi, none; T. Caceres Guajira, none; S. Tchernodrinski, none.