Successful Treatment of Severe Falciparum Malaria With Adjunctive Use of Exchange Transfusion

Abstract

A frequent traveller to malaria-endemic areas, a 50-yearold Canadian, without a significant medical history, returned from a 4-week trip to Nigeria. His malaria chemoprophylaxis was stopped prematurely due to side effects. During the trip, he adopted appropriate measures to prevent mosquito bites and was up-todate on his vaccinations. Four days after returning to Canada, he became ill; his symptoms included fever, chills, sweating, headache, and joint pains, followed by diarrhea, jaundice, shortness of breath, and a noticeable darkening of urine.He presented to a local hospital's emergency department where malaria was suspected; thin/thick blood smears confirmed an infection by Plasmodium falciparum. The parasitemia level was markedly high at 26%. Upon admission, he was in respiratory distress; his temperature was 38 °C, heart rate 118 beats/minute, blood pressure 110/70 mm Hg, respiratory rate 28/ minute, and oxygen saturation level 94%, using a 40% FIO2 face mask. The patient's physical examination revealed icterus, fine bilateral inspiratory crackles, tachycardia, and mild tender hepatomegaly. Figure 1 shows two peripheral blood smears taken from the patient which demonstrate red blood cells heavily infected with malaria parasites.The time between confirmation of his malaria diagnosis and the start of malaria treatment was approximately 1 hour. The patient's complete blood count showed a leukocyte count of 7. The patient's condition deteriorated rapidly in the emergency department, prior to admission to the critical care unit, where he was intubated, sedated, mechanically ventilated, and started on intravenous artesunate (2.4 mg/kg). A repeat chest x-ray revealed signs of acute respiratory distress syndrome (ARDS). Artesunate was re-administered at 12, 24, and 48 hours after the first dose.His hemoglobin levels dropped to 60 g/L, and his platelet count remained very low (12×10 3 /µL), necessitating multiple blood and platelet transfusions. A manual exchange transfusion (ET) was done within the first 24 hours, replacing 3000 mL of blood with 3517 mL; the duration of the ET was 8 hours.His renal function worsened, resulting in acute kidney failure, which required urgent hemodialysis. The patient's blood cultures were positive for Streptococcus pneumoniae and methicillin-sensitive Staphylococcus aureus. He was started on ceftriaxone (1 g intravenously daily), which was stepped down to amoxicillin/ clavulanic acid, based on culture sensitivities. CASE REPORT AbstractAlthough malaria is no longer endemic in Canada, it remains an important imported disease, principally among immigrants and travellers. The role of exchange transfusion in malaria treatment, in addition to standard anti-malarial treatment, remains controversial and is not well established. We report a case of severe malaria in a male traveller, complicated by multiorgan failure, septic shock, myositis, and unusual Streptococcus pneumoniae bacteremia. Manual exchange transfusion was used, in addition to artesunate-based therapy, and the patient respo...