COMMUNICABLE DISEASES. CLINICAL CASE 3. · CLINICAL CASE 3. Joaquin Salas. Poniente Hospital (Almería); Maria Jesus Pinazo ... Clinical and epidemiological history • A female patient

COMMUNICABLE DISEASES. CLINICAL CASE 3. Joaquin Salas. Poniente

Hospital (Almería); Maria Jesus Pinazo

and Joaquim

Gascón.

Hospital Clinical and Provincial (Barcelona); Sabino

Puente and Germain

Ramirez.

Carlos III Hospital

(Madrid)

• 8 year old girl from Senegal at the Reception Centre for the past 15 days.

• Speaks French.

• Pathological background: biannual malarial episodes that have been treated (parents do not remember the medication).

Personal background

• BP: 110/70mmHg. Weight: 28kg. FC 95x’• Good state of general health, BMI: 20.

Normohydrated, no jaundice. NO oedemas.• Head and neck: No adenopathies or thrush.• AC: rhythmic tones, no blowing. • AR: conserved gallbladder murmur• Abdomen: globular, soft, and depressible. No pain

in the palpations, mild splenomegalia, no hepatomegalia.

Physical exam

What complementary tests should be solicited?

• Thick smear • Complete blood count (CBC) test• Biochemistry with iron metabolism, liver profile

and proteins• Urine: sediment• Faecal parasites (x3)• Thoracic Rx• Abdominal ultrasound

Complementary tests solicited




Leukocytes: 3500 (35%S, 50% L, 15%Eos, 525 abs ).

Haemoglobin 10.5mg/dl; Htc 30%; MCV 80; MCH 30;

platelets 120.000/mm3.




Iron profile: normal.

Liver function: AST 55 UI/ml, ALT 58 UI/ml, GGT

49 IU/ml, LDH 608 IU/ml. BT/BD 2.5/0.5


and proteins• Urine: sediment: no pathological findings• Faecal parasites (x3)• Thoracic Rx• Abdominal ultrasound



and proteins• Urine: sediment• Faecal parasites (x3:) Strongyloides stercoralis• Thoracic Rx• Abdominal ultrasound



and proteins• Urine: sediment• Faecal parasites (x3:) Strongyloides stercoralis• Thoracic Rx: no pathology• Abdominal ultrasound



and proteins• Urine: sediment• Faecal parasites (x3:) Strongyloides stercoralis• Thoracic Rx• Abdominal ultrasound: homogeneous increase in

the size of the spleen.


• Thick smear• Complete blood count (CBC) test• Biochemistry with iron metabolism, liver profile

and proteins• Urine: sediment• Faecal parasites (x3:) Strongyloides stercoralis• Thoracic Rx• Abdominal ultrasound: homogeneous increase in

the size of the spleen.


Positive for P. falciparum

Parasitaemia 2.5%

• Broad differential diagnosis

• Non-specific signs and symptoms

• Lack of familiarity with imported diseases

Imported fever syndrome

Rational approximation

• Where is it from?• Start point and fever characteristics• Risks during the trip?• Vaccines?• Antimalarial prophylaxis?• Other symptoms?• Physical exam

Clinical and epidemiological history

• Where is it from?• Start point and fever characteristics• Risks during the trip?• Vaccines?• Antimalarial prophylaxis?• Other symptoms?• Physical exam

Clinical and epidemiological history

• A female patient has just arrived from Senegal, presenting an episode of progressive fever with 4 days’ evolution, in which the following evidence is given:

– Malaria by Plasmodium falciparum diagnosed by thick smear

• Mild leukopaenia• Normocytic anaemia• Altered liver function, hyperbilirubinaemia• Splenomegaly

– Eosinophilia strongyloidosis

Summary

ALL TROPICAL FEVERS

ARE MALARIA

UNTIL PROVEN OTHERWISE

It can be accompanied by headache, myalgia, cough, diarrhoea, vomiting,

abdominal pain…

Malaria

- World: 300-500 million cases

- World:1-2 million deaths

- European Union: 15,000-18,000 cases

- In the USA: 1,200-1,500 cases

- In Spain: > 400 cases

- Imported malaria: 2% mortality

Malaria

4 species of Plasmodium:

- Falciparum

- Vivax

- Ovale

- Malariae

Transmission: Anopheles mosquito bites (♀)

Malaria

Clinical presentation

- Malarial crisis: periodic shivering and fever

- Any other symptoms

- Nausea/vomiting, diarrhoea

- Respiratory symptoms

- Abdominal pain

…

Malaria

Some possible conditions that may affect symptoms:

- Non or semi-immunity.

- Special emphasis on P. falciparum!!!!

- High parasitaemias

- Resistance to conventional anti-malarial

medications

- Cytoadherence

Malaria

Diagnosis

-Microscopic

-Thick smear/film

-Parasitaemia

-Non-microscopic methods

-Parasite antigen detection: immunochromatography

-Antibodies (8-10 days following infection)

- Non-permanent: months-years.

Malaria

• CBC:

- Anaemia (infrequent)

- Normal or low leukocyte levels 95%

- Thrombocytopaenia 60-83%

• Biochemistry:

- Elevated LDH levels in 70-83%

- Indirect hyperbilirrubinaemia

- Moderate altered liver function

Malaria

1. What species are we working with?

2. Which drugs?

3. Treatment approach?

4. Outpatient treatment or admission?

5. Coadjuvant measures?

Five questions for the treatment of malaria:

Malaria


2. Which drugs?





Malaria

When in doubt,

THE MOST SERIOUS


2. Which drugs?





Malaria

P. ovale, P. malariae, P. vivax, chloroquine- sensitive

Chloroquine

P. falciparum chloroquine resistant

Quinine + Doxycycline Malarone

P. vivax chloroquine resistant

QuinineMalarone

+ Primaquine(G6PDH)

vivax, ovale

Malaria


2. Which drugs?

3. Treatment approach? ORAL vs PARENTERAL




Malaria

Vomiting PregnancySigns of complicationsParasitaemia > 2%

Convulsions Parasitaemia > 2%

Consciousness disorders Haemoglobin < 8gr/dL

Renal failure Acidosis (pH < 7.3)

Hypoglycaemia Shock

Acute pulmonary oedema or pulmonary distress Jaundice

Haemorrhagic manifestations/DIC Haemoglobinuria

Complicated malariaMalaria


2. Which drugs?





Malaria

P. falciparum

Need for a parenteral approach


2. Which drugs?





Malaria

Water balanceHypoglycaemiaAcid-base balanceHypoxaemiaSeizuresAnaemiaParasitaemia


2. Which drugs?





Malaria

- Corticosteroids- Heparin- Iron binders- Pentoxifylline- Exchange transfusion

- Parasitaemia > 30%- Parasitaemia > 10% in patients older than 60.

complications.

DIAGNOSIS

1.- MALARIA BY P. FALCIPARUM

2.- SPLENOMEGALIA SECONDARY TO MALARIA

3.- INTESTINAL PARASITOSIS BY S. STERCORALIS

Malaria

TREATMENT

1.- MALARIA BY P. FALCIPARUM

- Quinine 10mg/kg/8 h

+

- Doxycycline 100mg/ 12

2.- SPLENOMEGALIA SECONDARY TO MALARIA: control

3.- INTESTINAL PARASITOSIS BY S. STERCORALIS

- Ivermectin 200mcg/kg/day x 2 days

During 7 days

Malaria

EVOLUTION

Ad integrum resolution of the acute episode

- Clinical improvement

- CDC normalisation except eosinophils

- Normalisation of liver function

No new malarial crises in the following 6 months

Progressive descent in eosinophils until

normalisation in the following 6 months

Malaria

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COMMUNICABLE DISEASES. CLINICAL CASE 3. · CLINICAL CASE 3. Joaquin Salas. Poniente Hospital (Almería); Maria Jesus Pinazo ... Clinical and epidemiological history • A female patient