MULTIDISCIPLINARY CARE IN A CASE OF CEREBRAL MALARIA

Department of Critical Care Medicine

52 year old male patient:

Presented with 
 
                Fever
                Jaundice
                Breathlessness

• History of travel to Gujarat 2 weeks back
  
• Physical examination:

                Disorientation
                Jaundice
                Flapping tremor
                Hepatosplenomegaly

Investigations

• Hb: 9.4 gm%
• B.Urea: 98 mg%
• S.Creat: 0.7 mg%
  
  

ABG:
                pH – 7.48
                PCO2 – 21 mm Hg
                PO2 – 76 mm Hg
                ABE - -5
                SBE - -7
                SO2 – 90%
LFT:
                S.Bilirubin: 21.2 mg% (T); 15.2 mg% (D)
                S.Alb: 2.5 gm%
                S.Glob: 3.2 gm%
                AST: 89 U/L
                ALT: 72 U/L

Peripheral smear
             
              Malarial parasite positive
              Trophozoites and gametocytes of P.Falciparum seen

Diagnosis

• Complicated falciparum malaria

              Cerebral malaria
              Hepatitis
              Renal failure
              Severe intravascular hemolysis

• Bad prognostic indicators present:

              Persistent hypoglycemia
              Metabolic acidosis
              Hyperkalemia

Treatment

• nj. Quinine 600 mg IV q8h
• Inj. Larither (Artemesinin) 80 mg IM q12h

Clinical course

• Clinical deterioration over 2-3 days
  

ARDS
               Chest XRay: Bilateral lung infiltrates
               PaO2:FiO2 <200

• Intubated and ventilated on 4th day
• Deterioration of renal functions
• Hemodialysed from 5th day
• Nutrition maintained with TPN
• Extubated 2 weeks later
• Oral feeds started

• Hemodialysis continued daily
  
                                          Fever pattern in ICU
  
  

  

Clinical course

• Patient remained drowsy
• Reintubated following aspiration pneumonia 2 weeks later

Concomitant hemodynamic instability necessitated inotropic   support

• Hypotension – CRRT
• Stable hemodynamics - hemodialysis
• Tracheostomy one week later
• Anticipating prolonged weaning
• Protection of airways in view of persistent altered sensorium
• Nutrition maintained with nasojejunal feeds
• Patient weaned off the ventilator
• Hemodialysed till recovery of renal function

  IN HOSPITAL DETAILS

Multidisciplinary Care

Clinical course

• Patient discharged on 70th day
• Deafness
• Healing corneal ulcer

Review of literature

SOFA scoring system used to define organ failure in 301 ICU   patients with    severe malaria:

               CNS failure – 41%
               Renal failure – 30%
               Hematological failure – 44%
               Hepatic failure – 26%
               Respiratory failure – 26%
               Cardiovascular failure – 27%

(Krishnan A, Karnad DR: Crit Care Med 2003; 31: 2278-2284)

Cardiovascular failure:

2/3 presented with shock
Remaining developed septic shock during 2nd week of ICU  stay due to osocomial pneumonia and  primary bacteremia

 (Tran Royal Sc Trop Med Hyg 2000)

• Overall mortality 24.6%
• Increases to 49% if two organs affected and 80% if four   organs   affected
• Quinine drug of choice for severe malaria
• Artemesinin derivatives also useful

                causes faster reduction in parasitemia
                Resistance to artemesinin reported!

 (Kshirsagar NA et al. Ann Trop Med Parasitol 2000;94:519-520)
                Reserved for patients with severe malaria

History

8 year old girl
Stage III Neuroblastoma
Treated initially with chemotherapy and radiotherapy to   the abdomen
Relapsed 4 years after completion of treatment with bone   metastasis
Treated at another centre with complete response
Came to us for second opinion

Ideal candidate for High Dose Chemotherapy (HDCT)

Long disease free survival ( DFS )
Highly chemosensitive – complete response with salvage   chemotherapy

Initial assessment

BMA status – Evidence of malignancy
Cellularity
Vital organ function

Procedure

• Priming 
  
  Treatment with growth factors (G-CSF) for 5days for   mobilizing stem cells into peripheral circulation
  
  Harvesting of stem cells using pheresis machine
  
  Testing adequacy of collection and storage
  
  

        Procedure cont....

        Conditioning regimen
        High dose melphalan
        Reinfusion of stem cells 

        

                                        Course in hospital

Support required

Antibiotics for febrile neutropenia
Packed red cells
Platelet transfusion

Course in hospital

Engraftment on Day 15
Discharged on Day 17

FIRST PAEDIATRIC BONE MARROW TRANSPLANT IN KERALA.