A Case of Imported Severe Plasmodium falciparum Malaria in the Emergency Department and the Current Role of Exchange Transfusion Treatment

• Published in: The Journal of emergency medicine Vol. 44; no. 2; pp. e211 - e215
• Main Authors: Habeeb, Hania, MD, Ripper, Jill R., MD, Cohen, Alice, MD, Hinfey, Patrick B., MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.02.2013
• Subjects: Acute Kidney Injury - parasitology; Acute Kidney Injury - therapy; Antimalarials - therapeutic use; Doxycycline - therapeutic use; Emergency; Emergency Service, Hospital; exchange transfusion; Exchange Transfusion, Whole Blood; Female; Fluid Therapy; Humans; Hyperbilirubinemia - parasitology; Hyperbilirubinemia - therapy; Malaria, Falciparum - diagnosis; Malaria, Falciparum - therapy; Middle Aged; P. falciparum; Parasitemia - therapy; Platelet Transfusion; Quinidine - analogs & derivatives; Quinidine - therapeutic use; severe malaria; Severity of Illness Index; Thrombocytopenia - parasitology; Thrombocytopenia - therapy; Travel; exchange transfusion; severe malaria; P. falciparum
• ISSN: 0736-4679; 2352-5029
• DOI: 10.1016/j.jemermed.2012.02.051

Abstract Background The role of exchange transfusion in the management of severe malaria is not well documented in Emergency Medicine literature. Objectives The goal of this article is to review the importance of considering malaria in the differential diagnosis of the febrile returned traveler and to discuss the role of exchange transfusion in the management of severe Plasmodium falciparum malaria. Case Report A 59-year-old woman presented to the Emergency Department (ED) with severe P. falciparum malaria. Her physical examination was remarkable for scleral icterus, dry mucous membranes, and tachycardia. Her complete blood count revealed a white blood cell count of 6.9 k/uL, with 71% segmented neutrophils, 19% bands, a hemoglobin level of 11.9 g/dL, hematocrit of 37.2%, and a platelet count of 9 k/uL. Hepatorenal impairment was present and malaria parasites with ring form were seen on malaria prep in 18% of red blood cells. The patient was treated with fluids, platelets, quinidine gluconate, doxycycline, and exchange transfusion with significant improvement in the patient's clinical condition. Conclusions The high level of parasitemia presenting with acute kidney injury, hyperbilirubinemia, and thrombocytopenia supported the use of exchange transfusion as adjunct therapy. Exchange transfusion was a reasonable consideration in this case and was well tolerated by our patient. Institutions that are equipped with apheresis units should evaluate each case individually in concert with Centers for Disease Control experts and local consultants and weigh the risks and benefits of the use of exchange transfusion as an adjunct in the treatment of severe P. falciparum malaria.