Ditty and Pearls 6/8/16: Severe Malaria and GBS

Guillain-Barre Syndrome:

  • 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:

  • 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

 

  • 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

Evernote link:

https://www.evernote.com/shard/s354/sh/9a46fc6f-bc0b-4d34-b3a5-5245e156c36c/f8d046009adb314b85ba3410de90978e

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