Transcript Malaria Clinical Cases - Center for Health Services Research and

Malaria Clinical Cases
Presentation
Gail Stennies, M.D., M.P.H.
Medical Officer
Malaria Epidemiology Branch
DPD/ NCID/ CDC
May, 2002
Information requested when
evaluating a potential case of malaria
• Age
• Sex and pregnancy
status
• Travel history, travel
outside major or urban
areas
• Visitors from endemic
areas
• Exposure to
mosquitoes
• Malaria prophylaxis
used
• Receipt of blood
transfusions or
transplant
• Past history of malaria
• Drug allergies
• Clinical status of the
patient, esp.
neurological
• Lab results
Congenital malaria
• Previously healthy 10-week old female developed
an fever and dark urine on September 7, 2000
• Temp 103.7o F, WBC 24,600/µl, and
Hb 8.7 g/dL
• She was admitted for possible sepsis
• Blood, urine, and cerebral spinal fluid cultures were
done
• Treated with IV ampicillin and cefotaxime
Congenital malaria
• Past medical history
• Uncomplicated pregnancy and delivery
• Seen in ER on July 17 for abnormal breathing
• Normal exam and chest Xray, no diagnosis made or
treatment given
• Parents from DR Congo- dad came in 1995, mom
in 1996
• Mom completed course of chloroquine prior to
immigration for malaria (?self-diagnosis)
Congenital malaria
• Smears taken on September 8 showed P.m.
• Treatment with chloroquine was started
• She received 2 units of packed RBCs after
Hgb dropped to 5.6 g/dL
• Responded well to treatment with negative
smears 1 week post therapy
Congenital malaria
• Parents denied
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any episodes of malaria
febrile illness
foreign travel
or blood transfusion since in US
• Lived in screened apartment, some mosquitoes
seen indoors in August
• Friend from Kinshasha visited in August, he was
well during visit
Congenital malaria
• Pretreatment labs on mother
• Blood smears were negative
• Positive IgG titers
• P.f. and P.m. 1:16,384
• P.v. and P.o. 1:102
• PCR - negative
• Mother was treated empirically with
chloroquine
Transfusion-transmitted malaria
• 72 yo female with history of multiple
medical problems admitted September 15,
1995 with neutropenic fever post
chemotherapy
• Intracellular parasites found on peripheral
smear – diagnosed with Babesia
• Improved after quinine and clindamycin
were started on September 25
Transfusion-transmitted malaria
• Smears read as P.f. by CDC, same for smears from
September 4
• Risk factors
• No travel to endemic areas
• No IVDA, tattoos, acupuncture
• Yes recent recipient of blood
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April
August 9
September 3
September 9
September 24
quantity unknown
4 units
2 units
2 units
2 units
Transfusion-transmitted malaria
• Which units are most suspect?
• American Red Cross centers were notified
• Identify donors – defer for future donation during
investigation
• Put any unused blood products on hold
• Contact donors – reinterview about risk factors
• Obtain blood from donors – segments from units or
new collection for smears and serology
Transfusion-transmitted malaria
• 1/6 donors was Nigerian national with remote
history of malaria
• Thick & thin smears – too few parasites to identify
species at CDC
• Species
Index case
Donor N
P.v.
< 16
64
P.f.
1:1024
> 1:4096
P.m.
< 16
> 1:4096
P.o.
< 16
1:256
IFA results on other 5 donors were negative for all species
Donor N advised to seek treatment for P.f. and not donate
Unusual but possible case # 1
• 27 yo health care assistant with 3-day
history of fever, sweats, rigors & frontal
headache
• Past medical history was unremarkable
• Never had clinical malaria
• No recent foreign travel
• Left Sri Lanka 7.5 yrs earlier
• Visited France 3 yrs earlier
Unusual but possible case # 1
• Exam – 38.5o, no other abnormal findings,
no focal neurological signs
• Smears – P.f. , 0.001% parasitemia
• Started on oral quinine 600 mg 3x/day
• Initial increase in density to 0.005% but
after 5 days of treatment parasites cleared
• 3 tabs of Fansidar were given prior to
discharge
Unusual but possible case # 1
• ? Exposure
Unusual but possible case # 1
• 10 days prior to admission, he had sustained
a needlestick injury with a nonsterile needle
while resuscitating a patient
• Patient was 16 yo Ghanaian boy with P.f.,
1.7% parasitemia and febrile convulsion
• Haworth FLM, Cook CG. Needlestick malaria. Lancet
1995;346:1361.
Unusual but possible case # 2
• 28 yo English woman admitted to hospital on
April 20 1997, had been unwell for 3 weeks with
intermittent fever and diarrhea
• P. f. with 30% parasitemia was diagnosed
• Treated with IV quinine, blood transfusion, and
prostacyclin and recovered fully
• Traveled to Sub-Saharan Africa previous month
• Used chloroquine + proguanil for prophylaxis
Unusual but possible case # 2
• Flew to Italy on March 25, seen in Sicilian
hospital on April 16
• Given IV fluids and antibiotic, no specific
diagnosis made, was not admitted
• Was still ill when returned to England on
April 19
Unusual but possible case # 2
• Patient’s story is not unusual HOWEVER
• Italian physician who treated her died 21
days later on May 6
• Diagnosis of P.f was made on necropsy
• He had no travel history
• ?Risk
Unusual but possible case # 2
• He had sustained a needlestick injury with
the needle he used to start the woman’s IV
drip
• Anonymous. Needlestick malaria with tragic
consequences. Communicable Disease Report Weekly.
7(28)11 July 1997.
Unusual but possible case # 3
• 69 yo developed fever and chills on December 15,
1998 while at work
• Thick and thin smears showed rare intracellular
rings consistent with P.v. or P.o.
• The diagnosis was confirmed at a reputable
reference lab with PCR showing P.v.
• Patient did well with chloroquine and primaquine
Unusual but possible case # 3
• Patient denied recent blood transfusion or
international travel
• Last visit to a malarious area had been 10
yrs earlier
• Why is malaria on the differential diagnosis
list, esp. during cold and flu season?
Unusual but possible case # 3
• Occupational history?
Unusual but possible case # 3
• Occupational history?
• Parasitologist
• Denies recent needlestick exposure
• Hmm?
Unusual but possible case # 3
• During the 14 days prior to his illness, he
had worked in the insectory with infective
Anopheles mosquitoes carrying a Southeast
Asian strain of P.v. and a West African strain
of P.o.
• On December 8, a colleague had noticed a
mosquito flying free in the work area but
was unable to catch it
Things that keep risk management
staff busy - Case 1
• 31 yo female returned home to South Florida on
January 18, 1996 following a 16-day trip to
Bolivia
• No antimalarial chemoprophylaxis taken; had
significant rural exposure on trip
• Upon returning home she developed fever, chills,
headache and malaise and was admitted that same
day to Hospital A and evaluated for sepsis
Things that keep risk management
staff busy - Case 1
• Treated with IV antibiotics administered through a
heparin lock
• Blood films obtained on January 23, 1996 were
positive for P.v., later confirmed at CDC
• The patient was treated with oral chloroquine and
primaquine, improved promptly, and was
discharged on January 24, 1996
Things that keep risk management
staff busy - Case 2
• 83 yo male with multiple medical problems
including congestive heart failure and bradycardia
• Presented to another hospital in the same county
as Hospital A on February 11, 1996 with a history
of fever and chills
• P.v. parasites were identified on blood films
obtained for a complete blood count at the time of
admission.
• Diagnosis confirmed by CDC
Things that keep risk management
staff busy - Case 2
• Risk factors
• No history of travel outside the United States except for
visiting the Bahamas more than 10 years previously
• No IVDA or malariotherapy
• No recent blood transfusions
• From January 22-24, 1996 he had been admitted
to Hospital A for bradycardia
• Was in a room adjacent to that of Case 1
Things that keep risk management
staff busy - Case 2
• During that hospitalization he received
intravenous medications through a heparin
lock.
• The patient improved after treatment with
chloroquine and was discharged.
Things that keep risk management
staff busy - Déjà vu?
• 60 yo female patient with chronic obstructive
pulmonary disease presented to the hospital A on
February 12, 1996 with a similar history of fever
and chills
• P.v. parasites were identified on her admission
blood film, diagnosis confirmed at CDC
• Risk factors
• No travel outside the United States
• No IDVA or malariotherapy
• No recent transfusions of blood or blood products
Things that keep risk management
staff busy– Case 3
• However, she had also been hospitalized from
January 20-26, 1996 in a room adjacent to Case 1
• During that hospitalization, she had received IV
medications through a heparin lock
• The patient improved after treatment with
chloroquine and was discharged home.
Things that keep risk management
staff busy – Discussion
• Investigation by the County Health Department
and the hospital administration revealed
• All three patients had heparin locks at the same time
• All were cared for by the same health worker
• Deficient infection control practices
• In particular, nursing staff used 10 cc vials of sterile
water to flush heparin locks
• Occasionally used the same vial for two or more
patients
Things that keep risk management
staff busy - Discussion
• Although this practice could not be
retrospectively linked to the three cases, it
seems the most plausible explanation for
these three cases
• Following the investigation, the hospital
routinely began to use single-dose vials for
flushing intravenous devices
Management of induced or congenital
cases
• No sporozoites are injected into the human
by mosquito
• Therefore no exo-erythrocytic (hepatic)
cycle
• No need for primaquine
Malaria Life
Cycle
Oocyst
Sporozoites
Mosquito Salivary
Gland
Zygote
Exoerythrocytic
(hepatic) cycle
Gametocytes
Erythrocytic
Cycle
Hypnozoites
The following will become knee-jerk
questions
• Age
• Sex and pregnancy
status
• Travel history, travel
outside major or urban
areas
• Visitors from endemic
areas
• Exposure to
mosquitoes
• Malaria prophylaxis
used
• Receipt of blood
transfusions or
transplant
• Past history of malaria
• Drug allergies
• Clinical status of the
patient, esp.
neurological
• Labs
Don’t forget to ask
• Occupational history
• Healthcare workers
• Exposure to mosquitoes
• Needle exposure
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IV drug abuse
Needlestick injuries
Tattoos
Acupuncture
• Other meds used with
potential antimalarial effect
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Sulfa – Bactrim ®
Tetra – or doxycycline
Quinine
Hydroxychloroquine –
Plaquenil®
• Atovaquone
• Clindamycin
• Meds received abroad
• Artesunates
• Halofantrine
All “malaria” is not malaria
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Incubation periods unlikely
Parasite density very high for nonfalciparum
Species not likely given travel history
Drug resistance?
Misdiagnosis – species or parasite or negative
Miscalculation of density
Previously undetected mixed infection