Abstract
IntroductionMalaria is a potentially life-threatening disease, especially when complicated by a septic shock. When patients present in such a critical condition, the currently available literature allows a dilemma to develop as to which the correct treatment strategy is concerning fluid resuscitation.Case presentationA 55-year-old Caucasian man was admitted to the intensive care unit with the clinical picture of severe malaria, brought by a Plasmodium falciparum infection. On admission, the patient was confused, had high fever up to 40°C, and his blood analysis revealed a severe thrombocytopenia, a parasitemia of 25.5%, and biochemical features indicative of severe malaria. The patient received quinine and underwent two automated red cell exchanges by use of a centrifuge-driven cell separator. Two days after admission, the patient developed a septic shock. He received an "early-goal" treatment, according to the surviving sepsis campaign guidelines, which propose fluid resuscitation. The existing recommendations concerning the treatment of severe malaria that favour a restrictive fluid administration were disregarded. Fluid therapy was guided by regular measurements of the central venous pressure, blood pressure and monitoring of the hemodynamic status. The patient survived the shock and the subsequent multiorgan failure, which required mechanical ventilation and dialysis. After 12 days in the intensive care unit and an additional three weeks of hospitalization, the patient was discharged to rehabilitation.ConclusionThe authors believe that in patients with severe malaria complicated by septic shock, the treatment of sepsis and septic shock should be the one of first priority.
Highlights
Malaria is a potentially life-threatening disease, especially when complicated by a septic shock
When patients present in such a critical condition, the currently available literature allows a dilemma to develop as to which the correct treatment strategy is concerning fluid resuscitation
The authors believe that in patients with severe malaria complicated by septic shock, the treatment of sepsis and septic shock should be the one of first priority
Summary
A potentially life-threatening infectious disease, can become even more catastrophic when complicated by sepsis and septic shock. The heart rate decreased to 120 beats/min and the systolic blood pressure (SBP) increased to 100 mmHg with a mean arterial blood pressure (MAP) of 70 mmHg. The day, the parasite load of 25.5% on admission increased to 36.7%. As a consequence of the shock, the patient developed a severe hepatic dysfunction with a massive increase of liver enzymes and bilirubin and a decrease of albumin to one third of normal levels. With a positive fluid balance of almost 4 liters the fourth day, the patient remained hemodynamically stable. With a CVP between 9 and 13 the patient developed no pulmonary edema and all respiratory parameters remained stable. Based on CVP measurements, the net fluid balance was negative from day 5 on until discharge from the ICU. At the time of discharge creatine level was 286 μmol/l, renal function had been resumed and there was no need for further dialysis
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