Treatment of a patient with shock complicating severe falciparum malaria: a case report

Friedhelm Kuethe, Ruediger Pfeifer, Silke Rummler, Katharina Bauer, Virginia Kamvissi, Wolfgang Pfister

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. A 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 degrees 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. 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.