Transcript Monday Case presentation

Monday Case presentation
Beyond CDC recommendations
Presented by Nabil Khoury, MD
Disclosures
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None
History
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A 55 year AA male with DMI, who has just came
back from Nigeria 10 days prior, presents to the ER
for:
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Fever
Headaches
Myalgias
Vomiting
Abdominal pain
Malaria smear: positive
ID fellow paged at 1:00 AM for rec
Work-up
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WBC 5.9 Hb/Hct 12.7/36.6 Plt 101K
Na 133, K 4.2, CO2 26, BUN 15, Cr 1.1, Glc 280
AST 39, ALT 48, AP 72, Bil T 2.4 (I 1.8)
Now what?
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What if you were told the smear is negative?
What questions should you ask the ER
attending?
What drug should you recommend?
Complicated or Uncomplicated?
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Remember pathophysiology! RBC lysis and adherence
Review of systems: negative besides HPI, Diabetic
 No confusion - No dyspnea
Physical: including Vitals BP, HR, Pox, RR stable
Labs and Chest X-ray:
 No severe anemia
 No severe thrombocytopenia
 No acidosis
 No renal failure
 No hypoglycemia
 No severe hyperbilirubinemia
Did not take any prophylaxis
I told Dr Bell, it seems uncomplicated case of Malaria!!
Parasetemia? Type of Malaria?
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Parasitemia > 5% makes the case
complicated !
When parasitemia is > 2 %: frequently it is
Plasmodium Falciparum
In this case, it was a Saturday!
In our case Parasitemia 3.8%, P. Falciparum
Now, you got all the info, what is next?
Type of Malaria
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P. Falciparum: no liver hypnozoite
P. ovale and vivax: need to treat liver
hypnozoite with primaquine
Uncomplicated gets a little bit complicated
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Chloroquine sensitive v/s resistant areas
When in doubt consider it Chloroquine
resistant
CDC website: Malaria Map application
CDC guidelines
Uncomplicated P. falciparum
A. Atovaquone-proguanil(Malarone) x 3d
B. Artemether-lumefantrine(Coartem) x 3d
C. Quinine sulfate + doxy (or clinda)
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Quinine x 3 days
Doxy or Clinda x 7 days
D. Mefloquine: less recommended because of
severe neuropsychiatric side effects
A-B-C equally recommended
Atovaquone-proguanil (Malarone)
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Effectiveness: highly effective even in multi-drug
resistant areas 87-100% for P. Falciparum
Side effects: overall well tolerated
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Abd pain 13-31%
Diarrhea 6 – 8 %
Nausea 12%
Vomiting 1-19%
↑ LFTs 17-27%
Headache 10%
Cough 10%
Contraindicated if Cr Cl < 30
To be avoided if patient was on Malarone prophylaxis
Artemether-lumefantrine (Coartem)
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Effectiveness >95%  Rapid clearance : 1st choice WHO
Side effects: well tolerated
 Palpitations: 18%
 Potential for QT prolongation
 Abdominal pain 17%
 Diarrhea 7%
 Loss of appetite 40%
 Nausea 26%
 Vomiting 17%
 Arthralgias/Myalgias 34% / 32%
 Asthenia 38%
 Dizziness 39%
 Headache 56%
 Fever 25%
Quinine based regimens
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Efficacy > 90% except SE Asia
Side effects:
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May trigger hypoglycemia!
Cinchonism: frequent
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Tinnitus: reversible
Hearing loss: reversible
Headache
Nausea
Narrow therapeutic window that may lead to: rarely
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Cardiotoxicity
Blindness
Deafness
Complicated is easy!
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IV quinidine in ICU setting that may cause
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Ventricular arrhythmia
Hypotension
Prolongation of QT c
Hypoglycemia!
Monitor EKG for QT, QRS
v/s
IV artesunate from the CDC (IND?)
Consider exchange transfusion
Next day on Sunday
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His Fever was down and mildly symptomatic
Cr 1.1 Same
Hb dropped from 12.710.4
Plt dropped from 10164
Total Bil increased 2.45.6
ALT increased from 4865
AST increased from 3952
What happened?
Hospitalist concerned about G6PD deficiency!
Family asking for Coartem!
Anemia in Malaria
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He kept dropping progressively his Hb until it
stabilized at Hb of 9 (4%30%)
Most of the hemolysis affects non-infected RBC!
Up to 90% of lyzed RBCs are not infected
Multiple mechanisms of hemolysis:
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Oxidative stress
Bone marrow suppression
Increase phagocytic activity
Auto-immune anemia
Assessment of therapeutic response
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Parasite clearance times
Fever clearance times
WHO definitions of early treatment failure:
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Danger signs or severe malaria days 1-3 (+ parasitemia)
Parasitemia on day 2 > day 0
Parasitemia on day 3 with Temp>37.5 C(99.5F)
Parasitemia on day 3 of > 25% of day 0
G6PD Deficiency
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X-linked recessive disorder : Common in AA
Frequency: 10-15%
Type A in AA
Hemolysis is triggered by the malaria
infection itself and drugs: quinine/Primaquine
Hemolysis triggered by quinine is self-limited
even with continuous use of the drug
Coartem
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Family asking for Coartem
Accusing us of giving him an ineffective drug
to cut cost!
Coartem is very cheap!
Watch drug-drug interactions when switching