G374(P) Should automated rbc exchange transfusion be considered for severe malaria in resource rich setting

Abstract

Aim Review current guidance for Automated red blood cell (RBC) exchange transfusion in severe paediatric malaria. Methods Case presentation and review of published guidance. Result A 19 month Nigerian infant, recently arrived in the UK, was admitted following a focal seizure. He had a two day history of fever, coryza and diarrhoea. On presentation he was extremely unwell, tachypnoeic, tachycardic and encephalopathic with low GCS. Initial results confirmed profound metabolic acidosis (pH 6.86), high lactate (21 mmol/L), normal blood sugar (5.7 mmol), anaemia (haemoglobin 54 g/dl), thrombocytopenia (platelet 16 × 109/l), and coagulopathy with hepatorenal impairment. His peripheral blood smear showed plasmodium falciparum with 35% parasitaemia. Chest x-ray and CT head were normal; he had typical retinal haemorrhages on fundoscopy. He was admitted to PICU following intubation and ventilation and commenced on intravenous artesunate and broad spectrum antibiotics. Parasite load fell with IV artesunate from 35% to 25%. Due to severity of disease, after multi agency discussion with UK colleagues, he received an automated RBC exchange transfusion with good effect. He required blood product support and 4 days of haemofiltration for renal failure; abnormal liver function improved spontaneously. Due to ongoing positive parasitaemia he completed 5 days of intravneous artesunate followed by 6 doses of Artemether with Lumefantrine. After 9 days of intensive care and 14 days of hospital care he was discharged with normal MRI Brain and neurological examination with planned close follow up. Literature review RBC exchange in severely ill patients with hyperparasitaemia (i.e. >10%) appears to ‘improve blood rheological properties, capillary perfusion and microcirculatory flow. The Centers for Disease Control (CDC) recommends that exchange transfusion be strongly considered in hyperparasitaemia if complications such as cerebral malaria, pulmonary oedema, or renal compromise exist. Automated RBC exchange is safe and well tolerated and has the advantages of retaining plasma with antimalarial drugs and clotting factors and platelets. Conclusion This case highlights good response to RBC exchange transfusion in addition to artesunate. We suggest the theoretical advantages of RBC exchange transfusion should merit consideration in extremely ill patients with high parasite load, in a resource rich setting.