Cerebral Malaria Treated with Artemisinin in the Intensive Care Unit: A Case Report
AbstractMalaria is a parasitic disease that is starting to be encountered in intensive care units (ICU) worldwide, owing to increasing globalisation. Severe malaria caused by Plasmodium falciparum, is characterised by cerebral malaria, acute renal failure, hypoglycaemia, severe anaemia, splenomegaly and alveolar oedema. We present the case of a 25-yr old male patient who presented to the Emergency Department of Uludag University in Bursa, Turkey in the winter of 2014 with complaints of fever for three days. His medical history revealed a 14-month stay in Tanzania. Staining of blood smears revealed characteristic gametocytes in accordance with P. falciparum infection. The day after admission, he had an epileptic seizure after which his Glasgow Coma Scale was 6, so he was intubated and transferred to the ICU. A computerized tomography scan revealed findings of cerebral oedema. Intravenous mannitol was administered for 6 days. Intravenous artemisinin was continued for 10 days. Due to refractory fevers, anti-malarial treatment was switched to quinine and doxycycline on the 14th day and on the 16th day the fevers ceased. This case emphasizes that cerebral malaria should be suspected in cases of seizures accompanying malaria, and treatment should be initiated in the ICU. Furthermore, resistance of P. falciparum to artemisinin should be in mind when a response to therapy is lacking.
Gething PW, Patil AP, Smith DL, Guerra CA, Elyazar IR, Johnston GL, et al. A new world malaria map: Plasmodium falciparum endemicity in 2010. Malar J. 2011;10:378.
Murray CJ, Rosenfeld LC, Lim SS, Andrews KG, Foreman KJ, Haring D, et al. Global malaria mortality between 1980 and 2010: a systematic analysis. Lancet. 2012; 379 (9814):413-31.
White NJ, Pukrittayakamee S, Hien TT, Faiz MA, Mokuolu OA, Dondorp AM. Malaria. Lancet. 2014;383(9918):723-35.
Rosenthal PJ. Artesunate for the treatment of severe falciparum malaria. N Engl J Med. 2008;358(17):1829-36.
ter Kuile F, White NJ, Holloway P, Pasvol G, Krishna S. Plasmodium falciparum: in vitro studies of the pharmacodynamic properties of drugs used for the treatment of severe malaria. Exp Parasitol. 1993;76(1):85-95.
Kathryn Andrews MA, Richard Cibulskis, Cristin Fergus, Michael Lynch, Robert Newman, Zsofi a Szilagyi, Ryan Williams. World Malaria Report. 2013. 2012.
Reyburn H. New WHO guidelines for the treatment of malaria. BMJ. 2010;340:c2637. Epub 2010/06/01.
Postels DG, Birbeck GL. Cerebral malaria. Handbook of clinical neurology. 2013;114:91-102.
Parikh MP, Krishnan S, Ganipisetti VM, Flores S. Classic image: peripheral blood smear in a case of Plasmodium falciparum cerebral malaria. BMJ Case Rep. 2014;2014.
Idro R, Ndiritu M, Ogutu B, Mithwani S, Maitland K, Berkley J, et al. Burden, features, and outcome of neurological involvement in acute falciparum malaria in Kenyan children. JAMA. 2007;297(20):2232-40.
Warrell DA, Looareesuwan S, Warrell MJ, Kasemsarn P, Intaraprasert R, Bunnag D, et al. Dexamethasone proves deleterious in cerebral malaria. A double-blind trial in 100 comatose patients. N Engl J Med. 1982;306(6):313-9.
Mohanty S, Mishra SK, Patnaik R, Dutt AK, Pradhan S, Das B, et al. Brain swelling and mannitol therapy in adult cerebral malaria: a randomized trial. Clin Infect Dis. 2011; 53(4):349-55.
Okoromah CA, Afolabi BB, Wall EC. Mannitol and other osmotic diuretics as adjuncts for treating cerebral malaria. The Cochrane database of systematic reviews. 2011(4):CD004615.
Ashley EA, Dhorda M, Fairhurst RM, Amaratunga C, Lim P, Suon S, et al. Spread of artemisinin resistance in Plasmodium falciparum malaria. N Engl J Med. 2014;371(5):411-23.