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A
65 year old Caucasian woman has lived for 30 years in Nigeria. She has
taken chemoprophylaxis with primaquine, on a weekly basis. Whenever suspecting
a malaria attack, she has treated herself with chloroquine or artesunate.
Question
1: Among the chemoprophylaxis regimens below, which THREE would be most
suitable for Nigeria?
Question
2: If someone develops a suspected malaria attack while in Nigeria, but
cannot get laboratory confirmation within the next 24 hours, which ONE
of the options below would be the best for presumptive treatment?
(Assume that the person was not taking any chemoprophylaxis.)
This
woman has recently arrived in the United States. Six days after her arrival,
she falls and fractures her right wrist. The fracture is treated with
a splint and analgesics. Four days later she wakes up at 3 am with nausea,
retching and vomiting. She is taken by her daughter to a hospital where
she is found to be febrile to 103.4°F. This, combined with the history
of stay in Nigeria, prompts a blood smear that shows Plasmodium
falciparum
with an estimated parasitemia of 3%. Admission is advised but declined,
and the patient goes home under the care of her daughter (a physician),
with prescriptions for oral quinine and doxycycline. She starts taking
the drugs but vomits again. The following day her daughter finds her
to be lethargic, hardly able to lift a cup or to answer questions. The
patient is brought to another hospital. There, she is found to be febrile,
obtunded and unresponsive to painful stimuli. Laboratory findings include:
leucocytes 6,300/µL, platelets 40,000/µL, Hb 11 g/dL, creatinine
0.5 mg/dL, glucose 116 mg/dL. Seven hours later, she passes dark urine,
which is +++ for blood, +++ for protein, with 10-20 RBCs. Other laboratory
findings at that time include: hemoglobin 8.6 g/dL; reticulocytes 2.4%;
total bilirubin 6.2 mg/dL; LDH 444 U/L; AST 39 U/L; ALT 16 U/L; alkaline
phosphatase 61 U/L.
A
blood smear shows the following:
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Blood
smear of patient, Clinical Case No 3
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Question
3: What is the most likely diagnosis?
Question
4: Which of the following would be suitable for treatment? (more than
one might apply)
An
intravenous drip of quinidine is started. During the perfusion a prolongation
of the QT interval is noted (QT/QTC 444/534 ms), which resolves upon
readjustment of the quinidine drip. Shortly after the start of the IV
drip the patient's neurologic status improves. Thus, while preparations
had been made for an exchange transfusion, this is not carried out. Two
units of whole blood are transfused. The parasitemia decreases to 2%
the day after admission. On day 2 post admission, the parasites have
cleared. On day 4 post-admission the patient has completely recovered.
Main
points:
- Malaria should be considered in any patient who develops fever following
travel to a malaria-endemic area.
- Plasmodium falciparum malaria especially
in older patients is a potentially serious disease and should
be treated as a medical emergency.
- When complications develop (such as cerebral malaria and hemolysis)
an aggressive treatment with intravenous quinine/quinidine
and doxycycline can be life saving.
If doxycycline cannot be used, clindamycin could be an alternative.
Page last modified : April 23, 2004
Content source: Division of Parasitic Diseases
National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ZVED)
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