Correct!
5. All of the above
The patient became progressively more ill and decompensated into respiratory failure and a sepsis like syndrome. The patient then received a red blood cell exchange transfusion that evening administered by the Red Cross. This is thought to be beneficial by removing the parasite-infected cells and replacing them with donor non-affected cells. There are no prospective studies evaluating this therapeutic modality but retrospective studies show there may be some benefit. This therapeutic maneuver is also a recommendation by the CDC once the parasite load reaches greater than 10% or if there are indications of impending renal failure.
A few hours after the exchange transfusion the patient became progressively more tachycardic and then progressed into severe shock with his lactate climbing to 9.9 mmol/L, pH dropping to a nadir of 6.98, and requiring support with norepinephrine and phenylephrine. He received multiple boluses of normal saline throughout the evening but his vasopressor requirement did not diminish. This hypotension was thought to be possibly a side effect of intravenous quinidine therapy, which he was receiving at the time. Early the next morning the patient was still requiring significant doses of norepinephrine and phenylephrine. The patient was bolused with 1 liter of 5% albumin and the phenylephrine was able to be weaned off that morning and norepinephrine over the next two days. This coincided with the discontinuation of quinidine and the institution or artesunate. The issue of volume resuscitation in the setting of severe malaria is continually debated; most recently in the FEAST trial published in NEJM October 6, 2011.
Case Outcome
The malarial percentage on his initial smear was 8.5% on day 1, on day 2 it declined to 0.18% and on day 3 it was undetectable on the peripheral smear. He finished his artesunate therapy which was followed by atovaquone/proguanail for the next 3 days. He unfortunately did develop some sequelae from his acute malarial infection including splenomegaly with a small hematoma and renal failure which was treated by continuous renal replacement therapy then later transitioned to intermittent hemodialysis. The patient spent 7 days with us in the ICU and total of 3 weeks in the hospital before he was transferred back to a hospital in his hometown in Mexico.
References