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

133

4.1

101

23

8

0.879

3.235.2

51

8.5

1.9

1.1

152

2.0252

151

2.2

4.4

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.

Copyright restrictions may apply.

Griffith, K. S. et al. JAMA 2007;297:2264-2277.

Plasmodium Life Cycle

Copyright restrictions may apply. Griffith, K. S. et al. JAMA 2007;297:2264-2277.

Malaria Treatment Algorithm

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.

134

4.2

102

22

7

0.6208

2.830.1

33

6.3

3.6

2.2

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

26

9

0.790

5.731.7

11844

1.5152

152

2.7

LDH 774

Peripheral Smear: NO PARASITES Detected

D-dimer 914

UA Neg

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.