1. Monday Case presentation
Beyond CDC recommendations
Presented by Nabil Khoury, MD

2. Disclosures
None

3. History Malaria smear: positive
A 55 year AA male with DMI, who has just came back from Nigeria 10 days prior, presents to the ER for:
Fever
Headaches
Myalgias
Vomiting
Abdominal pain
Malaria smear: positive
ID fellow paged at 1:00 AM for rec

4. Work-up WBC 5.9 Hb/Hct 12.7/36.6 Plt 101K
Na 133, K 4.2, CO2 26, BUN 15, Cr 1.1, Glc 280
AST 39, ALT 48, AP 72, Bil T 2.4 (I 1.8)

5. Now what? What if you were told the smear is negative?
What questions should you ask the ER attending?
What drug should you recommend?

6. Complicated or Uncomplicated?
Remember pathophysiology! RBC lysis and adherence
Review of systems: negative besides HPI, Diabetic
No confusion - No dyspnea
Physical: including Vitals BP, HR, Pox, RR stable
Labs and Chest X-ray:
No severe anemia
No severe thrombocytopenia
No acidosis
No renal failure
No hypoglycemia
No severe hyperbilirubinemia
Did not take any prophylaxis
I told Dr Bell, it seems uncomplicated case of Malaria!!

7. Parasetemia? Type of Malaria?
Parasitemia > 5% makes the case complicated !
When parasitemia is > 2 %: frequently it is Plasmodium Falciparum
In this case, it was a Saturday!
In our case Parasitemia 3.8%, P. Falciparum
Now, you got all the info, what is next?

8. Type of Malaria P. Falciparum: no liver hypnozoite
P. ovale and vivax: need to treat liver hypnozoite with primaquine

9. Uncomplicated gets a little bit complicated
Chloroquine sensitive v/s resistant areas
When in doubt consider it Chloroquine resistant
CDC website: Malaria Map application

10. CDC guidelines Uncomplicated P. falciparum
A. Atovaquone-proguanil(Malarone) x 3d
B. Artemether-lumefantrine(Coartem) x 3d
C. Quinine sulfate + doxy (or clinda)
Quinine x 3 days
Doxy or Clinda x 7 days
D. Mefloquine: less recommended because of severe neuropsychiatric side effects
A-B-C equally recommended

11. Atovaquone-proguanil (Malarone)
Effectiveness: highly effective even in multi-drug resistant areas % for P. Falciparum
Side effects: overall well tolerated
Abd pain 13-31%
Diarrhea 6 – 8 %
Nausea 12%
Vomiting 1-19%
↑ LFTs 17-27%
Headache 10%
Cough 10%
Contraindicated if Cr Cl < 30
To be avoided if patient was on Malarone prophylaxis

12. Artemether-lumefantrine (Coartem)
Effectiveness >95%  Rapid clearance : 1st choice WHO
Side effects: well tolerated
Palpitations: 18%
Potential for QT prolongation
Abdominal pain 17%
Diarrhea 7%
Loss of appetite 40%
Nausea 26%
Vomiting 17%
Arthralgias/Myalgias 34% / 32%
Asthenia 38%
Dizziness 39%
Headache 56%
Fever 25%

13. Quinine based regimens
Efficacy > 90% except SE Asia
Side effects:
May trigger hypoglycemia!
Cinchonism: frequent
Tinnitus: reversible
Hearing loss: reversible
Headache
Nausea
Narrow therapeutic window that may lead to: rarely
Cardiotoxicity
Blindness
Deafness

14. Complicated is easy! IV quinidine in ICU setting that may cause v/s
Ventricular arrhythmia
Hypotension
Prolongation of QT c
Hypoglycemia!
Monitor EKG for QT, QRS
v/s
IV artesunate from the CDC (IND?)
Consider exchange transfusion

15. Next day on Sunday His Fever was down and mildly symptomatic
Cr 1.1 Same
Hb dropped from 12.710.4
Plt dropped from 10164
Total Bil increased 2.45.6
ALT increased from 4865
AST increased from 3952
What happened?
Hospitalist concerned about G6PD deficiency!
Family asking for Coartem!

17. Anemia in Malaria
He kept dropping progressively his Hb until it stabilized at Hb of 9 (4%30%)
Most of the hemolysis affects non-infected RBC!
Up to 90% of lyzed RBCs are not infected
Multiple mechanisms of hemolysis:
Oxidative stress
Bone marrow suppression
Increase phagocytic activity
Auto-immune anemia

18. Assessment of therapeutic response
Parasite clearance times
Fever clearance times
WHO definitions of early treatment failure:
Danger signs or severe malaria days 1-3 (+ parasitemia)
Parasitemia on day 2 > day 0
Parasitemia on day 3 with Temp>37.5 C(99.5F)
Parasitemia on day 3 of > 25% of day 0

19. G6PD Deficiency X-linked recessive disorder : Common in AA
Frequency: 10-15%
Type A in AA
Hemolysis is triggered by the malaria infection itself and drugs: quinine/Primaquine
Hemolysis triggered by quinine is self-limited even with continuous use of the drug

20. Coartem Family asking for Coartem
Accusing us of giving him an ineffective drug to cut cost!
Coartem is very cheap!
Watch drug-drug interactions when switching