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

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Unusual but possible case 1

• ? Exposure

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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.

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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

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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

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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

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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.

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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

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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?

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Unusual but possible case 3

• Occupational history?

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Unusual but possible case 3

• Occupational history?
• Parasitologist
• Denies recent needlestick exposure
• Hmm?

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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

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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

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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

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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

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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

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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.

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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

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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.

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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

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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

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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

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Malaria Life Cycle
Exo- erythrocytic (hepatic) cycle
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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

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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

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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