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A 40 year old man, resident of the United States, presents to an emergency room with a 5-day history of fever, chills, nausea, vomiting, and myalgias. He returned 2 weeks ago from a 16-day visit to Zambia.
Question
1:
What chemoprophylaxis regimen (if any) should be recommended for travel to Zambia?
(more than one might apply)
For this travel to Zambia, the patient had been prescribed chloroquine.
However, he took only a few doses during his visit. On the return
flight home, the patient had fever, nausea, and myalgias. Upon arrival
to the United States, the symptoms dissipated and the patient did
not seek medical care. Nine days later, he had again fever, chills,
nausea, vomiting, and myalgias. He went to an outpatient clinic where
he was diagnosed with viral syndrome and sent home.
Question
2: Based on the observed time intervals, could the symptoms experienced
by the patient be due to malaria?
Some days later, the patient was seen at another clinic, where on a
routine CBC malaria parasites were seen. He was then referred to a hospital,
where he presents to the emergency room, at 4 am, with continuing fever,
nausea, vomiting, and myalgias. On physical examination, the patient
is febrile (102°F), tachycardic. jaundiced and pale. He is well oriented
but slow in answering questions. A thin blood smear obtained while in
the emergency room is read as Plasmodium, species not determined. Other
laboratory findings include: hematocrit 33% , creatinine 3.6 mg/dL,
and total bilirubin 11.0 mg/dL. The urine is dark, with a measured output
of 40 mL/6 hours.
Question
3: Which one of the following would be the best next step in the clinical
management of this case?
The patient is admitted to the medical intensive care unit and treated with oral quinine and doxycycline. Later that day, the blood smear is reviewed by more experienced personnel for speciation.
Question
4: What is the diagnosis?
The smears are diagnosed as P. falciparum, and a parasite quantification shows that 17% of the erythrocytes are infected. The patient's mental status deteriorates and his urine output decreases.
Question 5:
Which of the following measures would be appropriate?
Treatment with oral antimalarials is continued and an exchange transfusion
is ordered. While preparing for the exchange transfusion, the patient becomes
hypotensive, requiring a dopamine drip. During the exchange transfusion,
the patient becomes increasingly tachypneic and develops atrial flutter,
which exacerbates the hypotension. DC cardioversion is attempted without
success. The patient develops asystole and expires 17 hours after admission
to the medical intensive care unit.
An autopsy was performed, but after a delay of 8 days. The gross findings show a slight swelling of the cerebral gyri, with consequent narrowing of the sulci; some blood vessels are engorged, with scattered petechial hemorrhage. The hematoxylin-eosin section of the brain shows autolysis, some pycnotic nuclei, and scattered pigment felt to be malarial in origin. The pigment and pinpoint hemorrhages are felt to be pre-mortem.
Main
points:
- Visitors to malaria endemic areas should take appropriate prophylaxis.
- Malaria should always be suspected in a febrile patient who has
recently traveled in a malaria endemic area.
- Blood smears for malaria should be examined by experienced staff,
without delay.
- When there is suspicion of severe malaria, the patient should
be hospitalized and parenteral treatment should be initiated urgently.
- Exchange transfusion should be considered when parasite density is
high (>10%) or when signs of cerebral or renal complications develop
(another indication, not present in this case, is non-overload
pulmonary edema).
Page last modified : July 30, 2004
Content source: Division of Parasitic Diseases
National Center for Zoonotic, Vector-Borne, and Enteric Diseases (ZVED)
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