Case Presentation:
A 56‐year‐old Nigerian female presented to the ED with 2 weeks of malaise, anorexia, and nausea. At the symptoms onset, she had returned from a month‐long trip to Nigeria to visit friends and relatives. Malaria chemoprophylaxis was not taken. On arrival, blood pressure was 99/55 and heart rate was 87. Fever and tachypnea were absent. Physical examination revealed lethargy and conjunctival rim pallor. Labs were significant for: Hb 7.4, platelets 80, BUN 141, Cr 6.7, AST 98, and ALT 54. Ring forms of Plasmodium falciparum were present on Giemsa‐stained blood smear with 1% estimated parasitemia. In keeping with CDC guidelines, the admitting team planned to treat this case of severe malaria with intravenous quinidine gluconate, but the drug was nonformulary and not immediately available. Instead, oral quinine and doxycycline were given per infectious diseases service/CDC malaria specialist recommendations. Although hemodialysis was required on hospital days 2 and 5 for oliguric renal failure, the patient remained afebrile, hemodynamically stable, and responded well to this second‐line therapy. Blood smears were negative after 7 days of therapy, and Ihe patient recovered with no long‐term sequelae.
Discussion:
Approximately 1500 cases of malaria occur in the United States every year. The majority of cases are uncomplicated and rapidly respond to ora therapy. However, 10% of cases meet criteria for severe disease (malaria with end‐organ damage and/orparasitemia>5%), which has a case fatality rate as high as 30% and for which rapid administration of an inlravenous antimalarial is the standard of care. Treatment of severe malaria in the United States is problematic. Only 1 intravenous drug is FDA approved for this condition: quinidine gluconate. With the advent of newer antiarrhythmic agents, this drug has rapidly disappeared from hospital formularies, and is often unavailable when urgently needed. Deaths secondary to quinidine unavailability are well documented in the literature. Since most deaths occur within 24 hours of presentation, the standard of care for severe malaria treatment is diagnosis to drug infusion time of less than 1 hour. In 2007, IV artesunate was made available in the United States under a CDC Investigational New Drug Application for use in severe malaria. The drug can be obtained from 1 of 8 quarantine stations, but the average time from request to infusion is 7 hours, rendering this a second‐line option.
Conclusions:
Falciparum malaria is a medical emergency that many hospitals are ill‐equipped to handle. Oplimal management of severe malaria requires advance planning, as the only FDA approved drug is often unavailable. In order to eliminate preventable deaths due to treatment delay, hospitalists should ensure that their facility stocks IV quinidine gluconate. Alternatively, arrangements can be made with neighboring hospitals to ensure emergent quinidine availability.
Author Disclosure:
S. Goldberg, none; L. Aybar, none; A. Khalil, none.