Exchange transfusion in severe falciparum malaria

Transfusion-associated falciparum malaria successfully treated with red blood cell exchange transfusion

Falciparum malaria is frequently associated with significant morbidity and mortality. The use of exchange transfusion as a therapeutic modality for severe cases of malaria has been described previously. We describe a case of a 49 year-old African American gentleman with a history of hemoglobin-SC disease who presented with a severe case of Plasmodium falciparum malaria 3 weeks after having received an infected blood transfusion. His peripheral smear showed the presence of numerous intraerythrocytic ring forms and "banana-shaped" gametocytes with a high-grade parasitemia, estimated at 18%. He was treated with antimalarial chemotherapy and also underwent a 12-unit red blood cell exchange transfusion, decreasing his parasite load to < 1%, as determined on repeat smear. It is prudent to be aware of the efficacy of this adjunctive treatment, especially with ever-increasing travel and a resultant increase in the prevalence of tropical diseases in the United States.

Comparative clinical characteristics and response to oral antimalarial therapy of children with and without Plasmodium falciparum hyperparasitaemia in an endemic area

The clinical characteristics and the responses to oral antimalarial therapy of 104 children presenting consecutively with or without Plasmodium falciparum hyperparasitaemia (HP) were investigated in an endemic area. At presentation, although the 52 children with HP were significantly younger and had significantly higher heart rates than the 52 without, there were no significant differences between the two groups in their symptoms or in any other clinical feature of their malaria. Responses to oral antimalarial drugs were similar in both groups. Analysis of the disposition kinetics of parasitaemia, using a non-compartmental model similar to that used in characterizing drug disposition, showed that the two groups had similar half-lives of parasitaemia (t1/2pd), volumes of blood completely cleared of parasites per unit time (CLBpd), and parasite-clearance-time:t1/2pd ratios. Three children in the HP group, all aged < 3 years, progressed to cerebral malaria within 8 h of presentation, and another HP child presented with isolated trunkal ataxia, indicative of cerebellar involvement. No child in the non-HP group had any of the features of severe malaria. Although the clinical characteristics and responses to oral therapy of children with and without HP are therefore very similar, young children with HP appear to have an increased risk of developing other features of severe malaria.

Hyperparasitaemia: not a reliable indicator of severity or poor prognosis in falciparum malaria in children in endemic African countries

Hyperparasitaemia as an indicator of severity or poor prognosis in falciparum malaria and response to oral antimalarial therapy were evaluated in an outpatient study of 77 consecutive African children from an endemic area. At presentation, clinical illness was graded as mild in 37, moderate in 14 and severe in 26. There was no evidence of renal, hepatic or cerebral complications. Clinical response to oral antimalarial drugs was characterized by rapid and uneventful recovery from illness in all but one patient who required hospital admission with prompt clearance of parasitaemia and fever within 96 hours. It is concluded that greater than 5% parasitaemia may be well tolerated by semi-immune African children. Semi-immune subjects with hyperparasitaemia and no other evidence of severe or complicated disease in an endemic area may well be treated with oral antimalarials providing the infecting strain is fully sensitive to the drug chosen and the drug is rapidly absorbed.

Treatment of severe malaria in the United States with a continuous infusion of quinidine gluconate and exchange transfusion

During the past decade the incidence of Plasmodium falciparum malaria in the United States has increased 10-fold. Treatment may be delayed because the therapy recommended for severe or complicated disease, intravenous quinine dihydrochloride, is available only from the Centers for Disease Control. We studied 17 patients who were treated for severe or complicated P. falciparum malaria in the United States between 1985 and 1987. Five patients were treated with a continuous infusion of quinidine gluconate, 10 with an exchange transfusion in addition to the continuous infusion of quinidine gluconate, and 2 with intermittently administered intravenous quinine dihydrochloride and an exchange transfusion. All 16 patients with P. falciparum malaria (1 patient had P. vivax malaria) had hyperparasitemia at the time of diagnosis (6 to 54 percent of the erythrocytes infected; median, 13 percent). Three patients with marked hyperparasitemia (54, 38, and 30 percent) and multiple other indicators of a poor prognosis, including advanced age, died. The 13 patients who completed their courses of quinidine with or without exchange transfusion had a parasitemia level of 1.1 percent or less 28 to 72 hours (mean, 44.4 hours) after the start of therapy. Side effects of quinidine treatment were observed in only two patients, one of whom had a serum quinidine concentration above the toxic level. We conclude that the continuous infusion of quinidine gluconate is well tolerated alone and with exchange transfusion and is effective in the treatment of severe and complicated malaria.

Malaria--an overview

The epidemiology, clinical features, diagnosis, prognosis, management, chemotherapy and chemoprophylaxis of malaria are reviewed.

Diagnosis of falciparum malaria delayed by long incubation period and misleading presenting symptoms: life-saving role of manual leucocyte differential count

In countries where malaria is not endemic the diagnosis of the disease is often delayed or overlooked, particularly if the clinical symptoms are atypical and if automated cell analyzers are used instead of blood films for leucocyte differential counts. We report 2 cases of severe Plasmodium falciparum malaria with unusual clinical features: a 46-year-old man with an exceptionally long incubation period and a 22-year-old woman with presenting symptoms suggesting viral hepatitis. In both cases the diagnosis of malaria was unexpectedly made by observant laboratory technicians examining stained blood films for differential counts.

[Treatment of fulminant falciparum malaria with erythrapheresis]

Ten days after his return from Cameroon, a twenty-six year old Frenchman, serving on voluntary service overseas, presented with fulminant falciparum malaria: shock, altered consciousness, haemolytic anaemia, threatening disseminated coagulation (platelets less than 150 X 10(-6).l-1; prothrombin time and Stuart factor less than 50%; fibrinogen less than 1.5 g.l-1). In spite of quinine therapy, parasitaemia increased from 4 to 35% within 24 h. Using an Haemonetics V50, the exchange of one and a half red blood cell masses was carried out with 17 red blood cell packs. Calcium gluconate was used to prevent the hypocalcaemia induced by the anticoagulant solution. The patient's platelets and plasma were completely reinjected. The result was very satisfactory. This kind of exchange, well tolerated clinically and biologically, would seem better than the classical exchange transfusion. When 10% of the red blood cells are infected by Plasmodium falciparum, it is necessary to exchange from one and a half to two blood masses. Lesser exchanges are always associated with important relapses and quinine therapy must be carried on during and after the exchange. Restricting this exchange only to red blood cells enabled the patient to benefit from his own coagulation factors, antibodies and platelets, and consequently to reduce the number of blood donors involved. However, metabolites (especially bilirubin and circulating immune complexes) were not eliminated. Partial plasmapheresis may be associated with erythropheresis using human albumin as plasma substitute. This technique needs to be assessed, in order to optimize immediate efficiency and post-transfusion infectious risk.