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A5329 - Malaria with Acute Respiratory Distress Syndrome: Developing Country Complications Seen in America
Author Block: R. Panjwani1, S. Davis2; 1GME, Medical City of Fort Worth, Fort Worth, TX, United States, 2GME, John Peter Smith, Fort Worth, TX, United States.
Introduction: Plasmodium falciparum is a parasite known to cause severe malaria manifesting as severe anemia, renal failure, and ARDS. Rarely in the United States, plasmodium vivax and ovale have been linked to these manifestations. Here we present a case of a patient found to have severe malaria due to plasmodium vivax and ovale who presented with sepsis due to an unknown source and developed ARDS, acute on chronic renal failure, and severe anemia.
Description: A 79 year old South Asian female with past medical history of hypertension and chronic kidney disease stage three initially admitted to the hospital with complaints of nausea, vomiting, diarrhea, myalgias, and intermittent fevers for one week. HR was 100, RR 26, temperature was 101. Workup was negative for infection except for gram positive blood culture, lactic acid of 2.4, procalcitonin of 29, and CRP of 10.5. She was found to have gram positive sepsis due to unknown etiology and was started on vancomycin and zosyn as well as fluid resuscitation. A few hours later, patient developed respiratory distress, RR increased to 50, temperature was 102, and NSVT unresponsive to adenosine and amiodarone. Subsequently, she was placed on an esmolol drip, Airvo, and transferred to the ICU. Over the next few days, results showed WBC 11, worsening anemia, thrombocytopenia, increasing creatinine, persistent fevers, and CXR suggested aspiration pneumonia and pulmonary vascular congestion. Respiratory status worsened and patient was intubated. The patient’s family revealed additional information regarding travel to India one year ago, which prompted evaluation for malaria. Malaria smear was positive for plasmodium vivax and ovale and patient was started on quinidine, linezolid, and merrem. Her hospital course was complicated by ARDS seen on CT chest, worsening renal status, and hemolysis. She was started on hemodialysis and received packed red blood cells. Overall, patient survived the course of treatment. She was discharged to long term acute care with a fourteen day course of primaquine in order to eradicate the hypnozoite phase.
Discussion: ARDS, hemolysis, and renal failure due to severe malaria is uncommon in the United States. With the ease of international travel, one should keep the differential of tropical diseases endemic to certain regions. When faced with sepsis with negative workup for typical bacterial, viral, and fungal sources that is not responding to therapy, it is important to consider remote travel history and possible parasite exposures as appropriate treatment can improve mortality.