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Malaria Clinical Cases Presentation

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Malaria Clinical Cases Presentation Gail Stennies, M.D., M.P.H. Medical Officer Malaria Epidemiology Branch DPD/ NCID/ CDC May, 2002 Information requested when ... – PowerPoint PPT presentation

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Title: Malaria Clinical Cases Presentation


1
Malaria Clinical Cases Presentation
  • Gail Stennies, M.D., M.P.H.
  • Medical Officer
  • Malaria Epidemiology Branch
  • DPD/ NCID/ CDC
  • May, 2002

2
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

3
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

4
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)

5
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

6
Congenital malaria
  • Parents denied
  • 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

7
Congenital malaria
  • Pretreatment labs on mother
  • Blood smears were negative
  • Positive IgG titers
  • P.f. and P.m. 116,384
  • P.v. and P.o. 1102
  • PCR - negative
  • Mother was treated empirically with chloroquine

8
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

9
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
  • April quantity unknown
  • August 9 4 units
  • September 3 2 units
  • September 9 2 units
  • September 24 2 units

10
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

11
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. lt 16 64
  • P.f. 11024 gt 14096
  • P.m. lt 16 gt 14096
  • P.o. lt 16 1256
  • IFA results on other 5 donors were negative for
    all species
  • Donor N advised to seek treatment for P.f. and
    not donate

12
Unusual but possible case 1
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

13
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

14
Unusual but possible case 1
  • ? Exposure

15
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
    19953461361.

16
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

17
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

18
Unusual but possible case 2
  • Patients 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

19
Unusual but possible case 2
  • He had sustained a needlestick injury with the
    needle he used to start the womans IV drip
  • Anonymous. Needlestick malaria with tragic
    consequences. Communicable Disease Report Weekly.
    7(28)11 July 1997.

20
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

21
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?

22
Unusual but possible case 3
  • Occupational history?

23
Unusual but possible case 3
  • Occupational history?
  • Parasitologist
  • Denies recent needlestick exposure
  • Hmm?

24
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

25
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

26
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

27
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

28
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

29
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.

30
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

31
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.

32
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

33
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

34
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

35
Malaria Life Cycle
Exo- erythrocytic (hepatic) cycle
36
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

37
Dont forget to ask
  • Occupational history
  • Healthcare workers
  • Exposure to mosquitoes
  • Needle exposure
  • IV drug abuse
  • Needlestick injuries
  • Tattoos
  • Acupuncture
  • Other meds used with potential antimalarial
    effect
  • Sulfa Bactrim
  • Tetra or doxycycline
  • Quinine
  • Hydroxychloroquine Plaquenil
  • Atovaquone
  • Clindamycin
  • Meds received abroad
  • Artesunates
  • Halofantrine

38
All malaria is not malaria
  • 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
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