///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

Fever of Unknown Origin in a Parturient: An Unexpected Case of Plasmodium Falciparum Malaria

Abstract Number: 269
Abstract Type: Case Report/Case Series

Deborah A. Brauer MD1 ; Donald H Penning MD2; Jayanthie S Ranasinghe MD3; Reine A Zbeidy MD4; Takeko Toyama MD5; David J. Birnbach MD, MPH6

Introduction: Malaria infection during pregnancy is a serious health problem in most of the worlds tropical regions. It can have serious repercussions for both mother and fetus.

Case Report: A 32 year-old, G2P0010, at 39-weeks of gestation presented to a US hospital with a one week history of intermittent fever, shaking chills, headache and cough. Between febrile episodes, she reported malaise, but was otherwise asymptomatic. She had no other significant medical history and her pregnancy was uncomplicated. The only recent travel was a trip to Haiti five months earlier. On admission her blood pressure was 95/50 mmHg, heart rate 160, respiratory rate 40 breaths/min and temperature of 103F. Blood culture, urine culture, chest x-ray and malaria blood smear were ordered. She was started on wide-spectrum antibiotics (vancomycin and piperacillin-tazobactam) plus intravenous fluids. No maternal anemia or thrombocytopenia was reported. Kidney and liver functions and coagulation profile were normal. She developed severe late fetal heart rate decelerations after approximately 6-hrs of labor and underwent emergent cesarean section under general anesthesia, with rapid sequence induction using etomidate and succinylcholine. Monitoring consisted of pulse oximetry, ECG and direct intra-arterial blood pressure measurement. She remained stable throughout the surgery and was extubated in the OR, then transferred to the ICU. She was started on quinidine and doxycycline because of a clinical suspicion of malaria although microbiology results were not immediately available. A peripheral blood smear eventually confirmed the diagnosis of malaria, by showing plasmodium falciparum infestation and a parasitic index of 1%. The patient was switched to chloroquine one gram orally for 48hours for a total of four doses. Complete recovery was achieved in one week.

Discussion: Malaria caused by P.falciparum is the most dangerous form of malaria. Early diagnosis and multidisciplinary management are essential. Malaria and pregnancy influence each other. Malaria can cause abortion, preterm labor, stillbirth and serious maternal morbidity and mortality. After the third month of pregnancy, the placenta is highly susceptible to malaria infection. The maternal sinusoids allow parasites to develop in the sequestered erythrocytes. Although our patient was a US citizen admitted to a hospital in Miami, she traveled to a malaria-infested area when she was nineteen weeks pregnant. General anesthesia was chosen because she exhibited signs of systemic sepsis prior to confirming the diagnosis of malaria. The role of regional anesthesia is controversial because of the possibility of seeding the CNS with the parasite.

References:

1) A. Bukman et al. International journal of Gynecology & Obstetrics 59 (1997) 143-144.

2) Fornet I et al. Rev Esp Anestesiol Reanim 2007 Dec;54(10): 626-9

SOAP 2009