Clinical Pathology Conference

12/9/2014Quention Nash

History Present Illness

42 yo AA F

CC: HeadachePt presents to the ED with HA, malaise, and vomiting for 5 days which are generalized. She recently returned from Sudan in the city of Guba for 1 month. She also reports relapsing fever over the past 3-5 days. She has had migraines before but feels this headache is different. Denies any exacerbating/remitting factors.

Review of Systems

Constitutional-Fever, sweating, chills, malaise, fatigue

GI-Nausea, Vomiting

MSK-Myalgias

Neurologic-HeadacheROS is otherwise negative

Past Medical History

MedicalDM II

Hypertension

Migraines

SurgicalAppendectomy

FamilyMother-Anemia

SocialNon-Smoker

Social Drinker

Physical Exam

VS101.1F

HR123

RR 24

BP 134/60

O2-98%

Physical Exam

General-Alert and oriented, mild distress

Integumentary-Moist, sweaty, no breakdown, henna tattoos

CV-Tachycardic, regular rhythm, no murmur

Physical Exam was otherwise unremarkable

Labs

WBC 9.3Hgb L 10.3Hct L 31.7Plt C 38Na L 134K 4.0CO2 22Cl 97Cr 0.7BUN 12Glucose H 160PT H 16.3INR 1.3PTT 29.4

Labs

DifferentialBands 13

Segs 78

Imaging

CXR-No acute cardiopulmonary disease

CT Head-No mass effect, no acute bleed

Tell story we were told

Malaria

Plasmodium Falciparum Life Cycle

Plasmodium Ring Forms
(Trophozoites)

Plasmodium Ring Forms

Merozoite matures to Trophozoite then Schizont (liver form)May reproduce asexually until the red blood cell lysis

May advance to Gametocyte form

Time period depends on speciesP. knowlesi: 24hrs

P. vivax, P. ovale, P. falciparum: 48hrs

P. malariae: 72hrs

Banana Bodies-P. falciparum
(Gametocytes)

Gametocytes

Gametocytes are the sexual stage and usually unique to the species

Difficult to determine sex from histology alone

Gametocytes do not cause symptoms

Complete reproduction in the Anopheles mosquito

Plasmodium Vivax
Schffner's dots (Left) and Microgamete (Right)

Plasmodium Vivax

Can see granulated inclusions or flagellated parasites in vitro

Plasmodium Ovale

Plasmodium Ovale

Large round Schizont with granular appearance slightly larger than RBC's

Plasmodium malariae

Plasmodium Malariae

Schizont slightly smaller than RBC with 6-12 merozoites with coarse appearance

Infected RBC's are smaller than uninfected RBC's

Approach to Malaria

DiagnosisHistory: Travel to malaria dense region, cyclical fevers, and drenching night sweats.

Physical Exam-pallor, petechiae, hepatomegaly, splenomegaly, mild jaundice

Labs-Anemia, elevated transaminases, acidosis(due to glypcolysis), elevated Cr

Incubation period for P. falciparum 12-14 daysP. vivax incubation period can be 18 days +

Regions Affected

Regions Affected

P. falciparum-throughout Africa

P. vivax-Asia, South America

P. malariae-South America, Asia and Africa

P. Ovale-Africa

P. knowlesi-South-east Asia

Treatment

>5% parasite load-IV quinidine for 7 days(or IV artesunate for 3 days where available)

Supportive management

Artesunate

MOA: Prodrug which is converted to dihydroartemisinin (DHA). DHA is an antimalarial agent active against all of the erythrocytic stages of the parasite including gametocytes; inhibits parasite metabolism and enhances the clearance of infected erythrocytes

SE: Hemolysis (increased with high viral load), Hypersensitivity, and QT prolongation

Available through U.S. investigational protocol

Generally only available if patient fails quinidine or quinidine is not readily available

Recommendations for Malaria Dense Travel

Clothing that reduces skin exposure

DEET containing insect spray

Sleeping with mosquito nets

ChemoprophylaxisAtovaquone-proguanil, mefloquine, doxycycline, primaquine, and chloroquine in areas without resistance

Innate resistance

Seen in patients with Hgb S, Hgb C, Hgb SC, Hgb E, Hgb F

Alpha Thalassemia

Beta Thalassemia

Duffy negative have P. vivax resistance

Hospital Course

Admitted and initially treated with quinidine and switched to artesunate

Discovered to have chronic cholycystitis

Developed sensorineural hearing loss most likely due to quinidine

Parasite load 0 at discharge

Parting Thoughts

3.4 billion people (half the worlds population) live in areas at risk of malaria transmission in 106 countries and territories

In 2012, malaria caused an estimated 207 million clinical episodes, and 627,000 deaths. An estimated 91% of deaths in 2010 were in the African Region.

#1 cause of death in several developing countries, especially affecting women and children