INTRODUCTION: Pulmonary involvement in Plasmodium falciparum malaria is frequently observed. It is associated with most malaria-associated deaths. The WHO (World Health Organization) recommends exchange transfusion (ET) in addition to standard pharmacologic therapy of quinidine or artemisinin derivatives in patients with severe malaria., especially those patients who develop coma, renal failure, or adult respiratory distress syndrome (ARDS) and is recommended regardless of the level of parasitemia, even less than 10%. However there are number of reports that question this modality of treatment. We present a case of 60-year-old male who presents to the hospital with complaints of fever, chills and shortness of breath. He was admitted and diagnosed with P. falciparum malaria, developed acute respiratory distress syndrome requiring mechanical ventilation. After intensive supportive care, treatment with intravenous quinidine and ET, the patient was eventually discharged.
CASE PRESENTATION: This is a 60-year-old male with past medical history of chronic obstructive pulmonary disease and malaria and recently arrived from Senegal, who was admitted to the hospital with complaints of shortness of breath, fever and chills for five days. He was diagnosed with P. falciparum malaria and was started on quinine and doxycycline orally. On the third hospital day he developed increased shortness of breath and increased oxygen requirements. A chest roentgenogram revealed diffuse bilateral infiltrates consistent with ARDS. He was transferred to the intensive care unit and intubated. In consultation with the infectious diseases service, oral quinine and doxycycline was discontinued and intravenous quinidine was substituted. His parasite load was 7.7%. Exchange transfusion was initiated for his ARDS and severe malaria. He improved dramatically, was extubated in 7 days and transferred out of the intensive care unit and discharged home after 12 days.
DISCUSSIONS: P. Falciparum is known to cause severe malaria and poses the greatest threat of death because it is often drug resistant, invades red cells of all ages, and the only one of the plasmodia species that produces microvascular disease. Our patient had a history of malaria and had recently traveled from an endemic area. He was diagnosed with P. falciparum infection with an initial parasite load of 7.7% and developed ARDS. The WHO recommend exchange transfusion for parasitemia greater than 10 % or for lower parasite loads in cases with evidence of organ dysfunction . Severe malaria is considered if the patient has jaundice, oliguria, altered consciousness, severe anemia and/or pulmonary edema. Theoretically, ET for severe malaria has 3 beneficial effects: (1) rapid reduction of parasitemia,  improvement of the red blood cell structure and morphology thus decreasing vascular obstruction and endothelial cell injury by the parasitized cells and (3) removal of pro-inflammatory cytokines. The true utility of this therapy is unclear as a number of studies question its role in severe malaria. However no randomized controlled trials have been conducted to analysis its efficacy . Our experience in this patient supports the use of exchange transfusion in severe malaria patients with ARDS.
CONCLUSION: In our patient with severe malaria and ARDS due to P. falciparum, exchange transfusion was successfully used in conjunction with intravenous quinidine and should be considered in other patients who present similarly.
DISCLOSURE: Sanjeev Kumar, None.