ESCMID SUMMER SCHOOL 200911- 17 July, Porto, Portugal

Georges KHALIL, MD, PhD(Paris7)

Department of Medical Microbiology Faculty of Medicine

Saint- Joseph University- Beirut, Lebanon

Student Case Presentation 11Monday, 13 July 2009, 13: 10- 13: 30

An unusual Complicated Case of Malaria

-Cerebral malaria is commonly the severe form of malaria

-However, other acute complications may occur

Our case illustrates an unusual severe presentation of malaria

A 43 years old Lebanese nun was admitted to the hospital for fever appearing one week later after her returning from Africa where she stayed 5 weeks in Gana.

She was taking Nivaquine° as

chemoprophylaxis !

The diagnosis of malaria due to Plasmodium falciparum was done

based on blood films.

She was treated by Mefloquine(Lariam⁰) one dose 750mg PO then 500 mg 6 hours later and 250 mg 12 hours later.

After the end of the treatment and 2 days fever free, the patient had more again a high fever (40- 41⁰C),

without any neurological symptoms or signs.

Parasitemia (of Plasmodium) searched on thick and thin blood

film was absent.

An extended work-up for tropical and other ID was done . All was

negative(TB,Brucella, Salmonella,HIV, HBV,BC,…).

TEE and high speed 64 multibarett CT-Scan of the chest, abdomen and pelvis were normal(apart an hepatosplenomegaly).

During this period, the nun developed a pancytopenia , high

ferritinemia(>2000 ng/ml), hypertriglyceridemia and high LDH.

A severe dyspnea due to ARDS (Acute Respiratory Distress

Syndrome) has leaded us to use the mechanical ventilation.

A sternal puncture was done

SP showed an hemophagocytic syndrome

CD68 marker of macrophages

Perls coloration+(Iron deposit)

Immunophénotypage médullaire

Lignée myélomonocytaire

Lignée lymphoïde

Immunophenotypage

Auto-immune check-up was also done

After 3 days of ventilation and iv methylprednisolone (500 mg bolus over 3 days),

the patient status recovered successfully.

ETIOLOGIES OF HEMOPHAGOCYTIC SYNDROME

Infections:-Virus: Herpes group-Bacteria: Mycobacteria-Parasites: Leishmania, PlasmodiumCancer: non- Hodgkin lymphomaAuto- immune disease: SLE, Still Disease, Juvenile arthritis Drugs: anti- seizures, minocycline, glucopeptide, cotrimoxazole, …Unkown

Larroche C and Mouthon L, Autoimmun Rev , 2004, 3: 69- 75

Hemophagocytic syndrome can be induced by either Plasmodium

falciparum or vivax malaria infection

Ohno T et al. Int J Hematol. 1996 Oct;64(3-4):263-6. Park Ts et al. Am J Hematol. 2003 Oct;74(2):127-30

Pahwa R et al. Indian J Pathol Microbiol. 2004 Jul;47(3):348-50