COMMUNICABLE DISEASES. CLINICAL CASE 3. Joaquin Salas. Poniente
Hospital (Almería); Maria Jesus Pinazo
and Joaquim
Gascón.
Hospital Clinical and Provincial (Barcelona); Sabino
Puente and Germain
Ramirez.
Carlos III Hospital
(Madrid)
• 8 year old girl from Senegal at the Reception Centre for the past 15 days.
• Speaks French.
• Pathological background: biannual malarial episodes that have been treated (parents do not remember the medication).
Personal background
• BP: 110/70mmHg. Weight: 28kg. FC 95x’• Good state of general health, BMI: 20.
Normohydrated, no jaundice. NO oedemas.• Head and neck: No adenopathies or thrush.• AC: rhythmic tones, no blowing. • AR: conserved gallbladder murmur• Abdomen: globular, soft, and depressible. No pain
in the palpations, mild splenomegalia, no hepatomegalia.
Physical exam
• Thick smear • Complete blood count (CBC) test• Biochemistry with iron metabolism, liver profile
and proteins• Urine: sediment• Faecal parasites (x3)• Thoracic Rx• Abdominal ultrasound
Complementary tests solicited
• Thick smear • Complete blood count (CBC) test• Biochemistry with iron metabolism, liver profile
and proteins• Urine: sediment• Faecal parasites (x3)• Thoracic Rx• Abdominal ultrasound
Complementary tests solicited
Leukocytes: 3500 (35%S, 50% L, 15%Eos, 525 abs ).
Haemoglobin 10.5mg/dl; Htc 30%; MCV 80; MCH 30;
platelets 120.000/mm3.
• Thick smear • Complete blood count (CBC) test• Biochemistry with iron metabolism, liver profile
and proteins• Urine: sediment• Faecal parasites (x3)• Thoracic Rx• Abdominal ultrasound
Complementary tests solicited
Iron profile: normal.
Liver function: AST 55 UI/ml, ALT 58 UI/ml, GGT
49 IU/ml, LDH 608 IU/ml. BT/BD 2.5/0.5
• Thick smear • Complete blood count (CBC) test• Biochemistry with iron metabolism, liver profile
and proteins• Urine: sediment: no pathological findings• Faecal parasites (x3)• Thoracic Rx• Abdominal ultrasound
Complementary tests solicited
• Thick smear • Complete blood count (CBC) test• Biochemistry with iron metabolism, liver profile
and proteins• Urine: sediment• Faecal parasites (x3:) Strongyloides stercoralis• Thoracic Rx• Abdominal ultrasound
Complementary tests solicited
• Thick smear • Complete blood count (CBC) test• Biochemistry with iron metabolism, liver profile
and proteins• Urine: sediment• Faecal parasites (x3:) Strongyloides stercoralis• Thoracic Rx: no pathology• Abdominal ultrasound
Complementary tests solicited
• Thick smear • Complete blood count (CBC) test• Biochemistry with iron metabolism, liver profile
and proteins• Urine: sediment• Faecal parasites (x3:) Strongyloides stercoralis• Thoracic Rx• Abdominal ultrasound: homogeneous increase in
the size of the spleen.
Complementary tests solicited
• Thick smear• Complete blood count (CBC) test• Biochemistry with iron metabolism, liver profile
and proteins• Urine: sediment• Faecal parasites (x3:) Strongyloides stercoralis• Thoracic Rx• Abdominal ultrasound: homogeneous increase in
the size of the spleen.
Complementary tests solicited
Positive for P. falciparum
Parasitaemia 2.5%
• Broad differential diagnosis
• Non-specific signs and symptoms
• Lack of familiarity with imported diseases
Imported fever syndrome
Rational approximation
• Where is it from?• Start point and fever characteristics• Risks during the trip?• Vaccines?• Antimalarial prophylaxis?• Other symptoms?• Physical exam
Clinical and epidemiological history
• Where is it from?• Start point and fever characteristics• Risks during the trip?• Vaccines?• Antimalarial prophylaxis?• Other symptoms?• Physical exam
Clinical and epidemiological history
• A female patient has just arrived from Senegal, presenting an episode of progressive fever with 4 days’ evolution, in which the following evidence is given:
– Malaria by Plasmodium falciparum diagnosed by thick smear
• Mild leukopaenia• Normocytic anaemia• Altered liver function, hyperbilirubinaemia• Splenomegaly
– Eosinophilia strongyloidosis
Summary
ALL TROPICAL FEVERS
ARE MALARIA
UNTIL PROVEN OTHERWISE
It can be accompanied by headache, myalgia, cough, diarrhoea, vomiting,
abdominal pain…
Malaria
- World: 300-500 million cases
- World:1-2 million deaths
- European Union: 15,000-18,000 cases
- In the USA: 1,200-1,500 cases
- In Spain: > 400 cases
- Imported malaria: 2% mortality
Malaria
4 species of Plasmodium:
- Falciparum
- Vivax
- Ovale
- Malariae
Transmission: Anopheles mosquito bites (♀)
Malaria
Clinical presentation
- Malarial crisis: periodic shivering and fever
- Any other symptoms
- Nausea/vomiting, diarrhoea
- Respiratory symptoms
- Abdominal pain
…
Malaria
Some possible conditions that may affect symptoms:
- Non or semi-immunity.
- Special emphasis on P. falciparum!!!!
- High parasitaemias
- Resistance to conventional anti-malarial
medications
- Cytoadherence
Malaria
Diagnosis
-Microscopic
-Thick smear/film
-Parasitaemia
-Non-microscopic methods
-Parasite antigen detection: immunochromatography
-Antibodies (8-10 days following infection)
- Non-permanent: months-years.
Malaria
• CBC:
- Anaemia (infrequent)
- Normal or low leukocyte levels 95%
- Thrombocytopaenia 60-83%
• Biochemistry:
- Elevated LDH levels in 70-83%
- Indirect hyperbilirrubinaemia
- Moderate altered liver function
Malaria
1. What species are we working with?
2. Which drugs?
3. Treatment approach?
4. Outpatient treatment or admission?
5. Coadjuvant measures?
Five questions for the treatment of malaria:
Malaria
1. What species are we working with?
2. Which drugs?
3. Treatment approach?
4. Outpatient treatment or admission?
5. Coadjuvant measures?
Five questions for the treatment of malaria:
Malaria
When in doubt,
THE MOST SERIOUS
1. What species are we working with?
2. Which drugs?
3. Treatment approach?
4. Outpatient treatment or admission?
5. Coadjuvant measures?
Five questions for the treatment of malaria:
Malaria
P. ovale, P. malariae, P. vivax, chloroquine- sensitive
Chloroquine
P. falciparum chloroquine resistant
Quinine + Doxycycline Malarone
P. vivax chloroquine resistant
QuinineMalarone
+ Primaquine(G6PDH)
vivax, ovale
Malaria
1. What species are we working with?
2. Which drugs?
3. Treatment approach? ORAL vs PARENTERAL
4. Outpatient treatment or admission?
5. Coadjuvant measures?
Five questions for the treatment of malaria:
Malaria
Vomiting PregnancySigns of complicationsParasitaemia > 2%
Convulsions Parasitaemia > 2%
Consciousness disorders Haemoglobin < 8gr/dL
Renal failure Acidosis (pH < 7.3)
Hypoglycaemia Shock
Acute pulmonary oedema or pulmonary distress Jaundice
Haemorrhagic manifestations/DIC Haemoglobinuria
Complicated malariaMalaria
1. What species are we working with?
2. Which drugs?
3. Treatment approach?
4. Outpatient treatment or admission?
5. Coadjuvant measures?
Five questions for the treatment of malaria:
Malaria
P. falciparum
Need for a parenteral approach
1. What species are we working with?
2. Which drugs?
3. Treatment approach?
4. Outpatient treatment or admission?
5. Coadjuvant measures?
Five questions for the treatment of malaria:
Malaria
Water balanceHypoglycaemiaAcid-base balanceHypoxaemiaSeizuresAnaemiaParasitaemia
1. What species are we working with?
2. Which drugs?
3. Treatment approach?
4. Outpatient treatment or admission?
5. Coadjuvant measures?
Five questions for the treatment of malaria:
Malaria
- Corticosteroids- Heparin- Iron binders- Pentoxifylline- Exchange transfusion
- Parasitaemia > 30%- Parasitaemia > 10% in patients older than 60.
complications.
DIAGNOSIS
1.- MALARIA BY P. FALCIPARUM
2.- SPLENOMEGALIA SECONDARY TO MALARIA
3.- INTESTINAL PARASITOSIS BY S. STERCORALIS
Malaria
TREATMENT
1.- MALARIA BY P. FALCIPARUM
- Quinine 10mg/kg/8 h
+
- Doxycycline 100mg/ 12
2.- SPLENOMEGALIA SECONDARY TO MALARIA: control
3.- INTESTINAL PARASITOSIS BY S. STERCORALIS
- Ivermectin 200mcg/kg/day x 2 days
During 7 days
Malaria
EVOLUTION
Ad integrum resolution of the acute episode
- Clinical improvement
- CDC normalisation except eosinophils
- Normalisation of liver function
No new malarial crises in the following 6 months
Progressive descent in eosinophils until
normalisation in the following 6 months
Malaria