Page 169 - Medical Parasitology_ A Textbook ( PDFDrive )

162 14 Case Reports

diffuse infiltrates. The patient had renal failure (creatinine 330 μmol/L). Haemodialysis
was commenced with other supportive ICU care. Intravenous artesunate was com-
menced; however, the patient remained on maximum inotropic and ventilator sup-
port. He died 9 h later with multiple organ failure. Blood cultures and dengue
serology were negative, and PCR performed on a blood sample taken on day 3 con-
firmed P. knowlesi mono-infection. Cause of death was reported as severe malaria.

Learning Points
1. Plasmodium malariae infection does not usually cause high parasitaemia and
symptoms are usually mild. If atypical P. malariae infection is encountered, it
should alert the clinician of the possibility of P. knowlesi infection to guide them
in treatment since P. knowlesi is known to cause severe infection.
2. Although blood film for malaria parasites (BFMP) is a gold standard diagnostic
test, it cannot differentiate morphologically P. knowlesi from P. malariae.
3. Clinicians must be vigilant in picking up the signs and symptoms of severe
malaria.
4. Clinicians must be aware of non-falciparum Plasmodium species as potential
cause of severe and fatal malaria. Patients who present with severe malaria
should be commenced with intravenous anti-malarial treatment.

Source: Rajahram GS, Barber BE, William T, Menon J, Anstey NM, Yeo TW.
Deaths due to Plasmodium knowlesi malaria in Sabah, Malaysia: association
with reporting as Plasmodium malariae and delayed parenteral artesunate.
Malaria Journal 2012, 11:284.

Case report 2: A 71-year-old female with a history of hypertension was
admitted to a district hospital for fever associated with chills and rigors, myalgia
and arthralgia. She had stayed overnight at her palm oil and rubber plantation in
the forest fringe 10 days prior to becoming unwell. On admission, she was alert
but jaundiced and tachypnoeic with a respiratory rate of 38 breaths per minute,
and the oxygen saturation was 98% on room air. The blood pressure was
127/87 mmHg, pulse rate was 111 bpm and temperature was 37.8 °C. She had
hepatomegaly and bilateral lower zone crepitations were heard on respiratory
examination. Chest radiograph was normal. Blood film for malaria parasites
(BFMP) was reported as Plasmodium malariae with a parasite count of 120,000
parasites/μL. The patient was commenced on intravenous artesunate, oral doxy-
cycline and intravenous ceftriaxone within 2 h of presentation. However, her
condition deteriorated rapidly, with oxygen saturation decreasing to 70% on 15 L
of oxygen, and blood pressure dropping to 80/50 mmHg. She was intubated,
transferred to the intensive care unit and commenced on dopamine, dobutamine
and noradrenaline. Chest radiograph post intubation showed bilateral diffuse het-
erogenous opacities, and she died 18 h after presentation from severe malaria
with acute respiratory distress syndrome (ARDS). PCR performed on the extract