ID Case Conference
Yvonne L. Carter, MD
11 June 2008
Headaches and Fever




41yo female physician with a 3-day h/o
headaches and fever
Began 3 days ago, fever and HA controlled
with Tylenol…after which she feels better, but
develops uncontrollable chills ~1 hour after
dose
Denies neck stiffness, visual changes, or
other neurological symptoms
HA currently 6/10. Pt also reports myalgias,
but otherwise feels well, and would like to go
home.
History



Pt is a Tropical Medicine Physician.
She works in the Rep. Of Congo, and had
been there for four months
Had received travelers vaccinations
– Typhoid, Rabies, Japanese Encephalitis, Yellow
Fever

PMH
– Hepatitis A (remote)
– Appendicitis, with
Appendectomy
– HIV negative

Meds
– Prn Tylenol

Allergies
– PCN - rash

SocHx
–
–
–
–
Married
Lives in Chapel Hill
No pets
Travel: recent travel
to The Republic of
Congo, Africa
– Denies tobacco,
Etoh, or illicits
– No ill contacts
Physical Examination









VS: T 36.3, P 103, BP 115/76, R 20, Pox 100% on RA
Gen: WD, WN thin CF who appears uncomfortable, holding
head, speaking softly
HEENT: NCAT, Perrla, Eomi, Sclera anicteric, conj pink, MMM,
OP clear, Neck supple, No LAD.
CV: Tachycardic, II/VI SEM at apex w/o radiation
Pulm: CTA b/l, no w/r/r
Abd: Soft, ND, NT, no organomegaly
Ext: No c/c/e
Neuro: Normal exam, no focal deficits
Skin: No rashes
Laboratory Data
8.5
133
4.1
101
8
23
0.8
3.2
1.1
1.9
79
152
151
4.4
252
2.0
2.2
51
35.2
Discussion
What I left out…





Mefloquine had caused dizziness in the past,
therefore the pt did not take prophylaxis
Used bed nets and insect repellants
throughout the trip, with success…
Until the last week of her trip, she was bitten
on the Lower Exts, Abdomen, and Back
Developed a “tingling sensation” at the site of
the bites on the trunk…locals suggested this
was indicative of malaria transmission
Pt was given a dose of an “untraditional”
treatment for malaria by local doctors
P. falciparum, 24%
Sub-Saharan Africa
(Cases per 1000 patients with syndrome)

Systemic Febrile Illness = 718
– Malaria – 622
– Dengue – 7
– Mononucleosis (EBV/CMV) – 10
– Rickettsial infection – 56
– Salmonella typhi or S. paratyphi – 7

No specific cause reported = 282
NEJM 354(2):119-130.
Plasmodium Life Cycle
Griffith, K. S. et al. JAMA 2007;297:2264-2277.
Copyright restrictions may apply.
Malaria Treatment Algorithm
Copyright restrictions may apply.
Griffith, K. S. et al. JAMA 2007;297:2264-2277.
Severe malaria
Severe malaria if…
 Parasitemia of >5%
 Altered consciousness
 Oliguria
 Jaundice
 Severe normocytic
anemia
 Hypoglycemia
 Organ failure








Seizures
Acute renal failure
Fluid and electrolyte
abnormalities
Metabolic acidosis
Acute respiratory distress
syndrome
Circulatory collapse or shock
Hemoglobinuria
Bleeding
Exchange transfusion Rx

Recommended in P. falciparum infection
when…
– Parasitemia is greater than 10%
– Patients with coma, renal failure or ARDS
regardless of the level of parasitemia.



Should be combined with drug therapy
Should be continued until the level of
parasitemia is <5%
Does not enhance survival
Exchange Transfusion
(Meta-Analysis)




Meta-analysis
No greater survival rate among patients who
received exchange transfusion compared to
antimalarials alone
Patients who received exchange transfusions
had higher degrees of parasitemia and more
severe disease – not comparable to those
receiving medications alone
No RCT has been performed
Clin Infect Dis 2002;34(9):1192-8.
Hospital Course



Pt treated with IV Quinidine and Doxycycline,
Exchange Transfusion via Right Subclavian
IV Quinidine initiated ~9:30pm, and bolused
over four hours. Pt developed nausea,
vomiting, and profuse watery diarrhea.
Exchange transfusion began at ~11pm, pt
developed asymptomatic hypotension (SBP
80s), and exchange prematurely discontinued
at 7/8 units complete.
Hospital Course, cont.




Pt became bradycardic, with a pulse in 60s.
QTc prolonged to 541ms, after IV Quinidine
bolus finished.
1am: Parasitemia 9%
9am: Parasitemia 6%, QTc 510
Hospital Course, cont.
6.3
134
4.2
102
7
22
0.6
2.8
33
30.1
208
2.2
3.6
Discharge
Recommended switch to po Quinine
and Doxycycline…Pt refused
 Pt discharged on Malarone
(Atovaquone/Plaguanil) to complete
three day course.
 Pt discharged on hospital day #2, with a
parasitemia <1%

BUT…
Pt called UNC two days later,
complaining of SOB, and was instructed
to walk in to the ID Clinic
 Orthopnea, Pleuritic CP, and facial
swelling
 Temp 37.0, BP 105/62, P 89, RR 16
Pox 85%
 ABG: 7.49/34/54/89% on RA

136
3.6
102
9
26
0.7
90
LDH 774
D-dimer 914
UA Neg
5.7
44
152
152
1.5
118
31.7
2.7
Peripheral Smear: NO PARASITES Detected
Diagnostic Studies
Cardiac enzymes negative
 CTA negative for PE
 TTE Normal
 Bronchoscopy:

– No gross abnormalities
– Gram Stain Negative, Culture Negative
Bronchoscopy

BAL Fluid
– Color: Pink
– Appearance: Cloudy
– TNC: 1100
• Neut 2
• Lymph 30
• Mono 57
– RBC 6950
– Macrophages
present









PCP DF : Neg
CMV PCR: Neg
Legionella: Neg
Cx: Negative
Viral Cx: Negative
Fungal Cx: Negative
C. pna Cx: Negative
Mycoplasma:
Negative
AFBs: Negative
Differential Diagnosis –
Pulmonary Edema
Drug-Induced Alveolitis
 BOOP (Cryptogenic Organizing Pna)
 Acute Lung Injury due to Malaria
 ARDS
 Atypical Pneumonia
 Diffuse Aspiration

Discharge

Pt refused to stay longer, and was
discharged on Levaquin, for a total
course of 14 days.