- Plasma exchange reduces the need for and duration of mechanical ventilation in patients with GBS as compared to supportive care.
- Close airway monitoring is crucial in these patients to prevent respiratory failure – send to ICU, check serial FVCs.
- Malaria lifecycle per the CDC is below. Focus on the schizont and immature trophozoite forms which are potentially captured on the photos of this pt’s smears, see below.
- Severe malaria is defined as 1 or more of the following in absence of an alternative cause AND in the presence of P. falciparum parasitemia.
- Impaired consciousness: Glasgow coma score <11
- Prostration: Generalized weakness so that a person is unable to sit, stand, or walk without assistance
- Convulsions: More than two episodes within 24 hours
- Acidosis: A base deficit of >8 mEq/L, a plasma bicarbonate level of <15 mmol/L, or venous plasma lactate ≥5 mmol/L. Clinical indicators of acidosis include rapid, deep, labored breathing
- Hypoglycemia: Blood or plasma glucose <40 mg/dL
- Severe anemia: hgb <7, hct <20 with with parasite count >10,000/mcL (0.2 percent parasitemia)
- Renal impairment: Plasma or serum creatinine >3 mg/dL (265 mcmol/L) or blood urea >20 mmol/L
- Jaundice: Plasma or serum bilirubin >50 mcmol/L (3 mg/dL) with a parasite count >100,000/mcL (0.2 percent parasitemia)
- Pulmonary edema/ARDS: Radiographically confirmed or oxygen saturation <92 percent on room air with respiratory rate >30/minutes, often with chest indrawing and crepitation on auscultation
- Significant bleeding: Including recurrent or prolonged bleeding (from the nose, gums, or venipuncture sites), hematemesis, or melena
- Shock: Compensated shock is defined as capillary refill ≥3 seconds or temperature gradient on leg (mid to proximal limb), but no hypotension. Decompensated shock is defined as systolic blood pressure >80 mmHg, with evidence of impaired perfusion (cool peripheries or prolonged capillary refill)
- Hyperparasitemia: P. falciparum parasitemia >10 % (>500,000/mcL)
- Severe P. vivax malaria has the same criteria above except WITHOUT parasite density thresholds
- Malaria Treatment
- Depends on
- clinical syndrome: uncomplicated vs complicated/severe
- Malaria species
- Resistance patterns (high in P. falciparum, lower in P. vivax)
- Reference CDC guidelines and discuss w/ ID colleagues re: ultimate plan http://www.cdc.gov/malaria/resources/pdf/treatmenttable.pdf
- Malarone available for uncomplicated malaria and as part of combination therapy with artesunate
- For severe, goal is to treat asap and usually IV
- Artemisinin derivatives are preferred as they clear parasitemia faster than quinine and have lower mortality rates
- If pt can’t take PO (artemether)and/or IV artemisinins (artesunate) not available or meeting of severe criteria is in question, can use IV quinidine plus doxycycline (doxy given the quinidine is short acting)
- Monitor EKG for QT prolongation with quinidine given class I anti-arrhythmic drug
- Quinidine can act as pancreatic secretagogues, leading to hyperinsulinemic hypoglycemia
- Depends on
- Faget’s sign: fever-pulse dissociation, also called sphygmothermic dissociation which occurs with Salmonella typhi infection
Griffith KS, Lewis LS, Mali S, Parise ME. Treatment of Malaria in the United States: A Systematic Review. JAMA. 2007;297(20):2264-2277. http://jama.jamanetwork.com/article.aspx?articleid=207162
Dondorp A et al. Artesunate versus quinine in the treatment of severe falciparum malaria in African children (AQUAMAT): an open-label, randomised trial. The Lancet. 2010;376 (9753): 1647-57. http://www.sciencedirect.com/science/article/pii/S0140673610619241