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Student Case Presentation 11 Monday, 13 July 2009, 13: 10- 13: 30

ESCMID SUMMER SCHOOL 2009 11- 17 July, Porto, Portugal Georges KHALIL, MD, PhD(Paris7) Department of Medical Microbiology Faculty of Medicine Saint- Joseph University- Beirut, Lebanon. Student Case Presentation 11 Monday, 13 July 2009, 13: 10- 13: 30. An unusual Complicated Case of Malaria.

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Student Case Presentation 11 Monday, 13 July 2009, 13: 10- 13: 30

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  1. ESCMID SUMMER SCHOOL 200911- 17 July, Porto, PortugalGeorges KHALIL, MD, PhD(Paris7)Department of Medical Microbiology Faculty of Medicine Saint- Joseph University- Beirut, Lebanon

  2. Student Case Presentation 11Monday, 13 July 2009, 13: 10- 13: 30

  3. An unusual Complicated Case of Malaria

  4. -Cerebral malaria is commonly the severe form of malaria -However, other acute complications may occur

  5. Our case illustrates an unusual severe presentation of malaria

  6. A 43 years old Lebanese nun was admitted to the hospital for fever appearing one week later after her returning from Africa where she stayed 5 weeks in Gana.

  7. She was taking Nivaquine° as chemoprophylaxis !

  8. The diagnosis of malaria due to Plasmodium falciparum was done based on blood films.

  9. She was treated by Mefloquine(Lariam⁰) one dose 750mg PO then 500 mg 6 hours later and 250 mg 12 hours later.

  10. After the end of the treatment and 2 days fever free, the patient had more again a high fever (40- 41⁰C), without any neurological symptoms or signs.

  11. Parasitemia (of Plasmodium) searched on thick and thin blood film was absent.

  12. An extended work-up for tropical and other ID was done . All was negative(TB,Brucella, Salmonella,HIV, HBV,BC,…). TEE and high speed 64 multibarett CT-Scan of the chest, abdomen and pelvis were normal(apart an hepatosplenomegaly).

  13. During this period, the nun developed a pancytopenia , high ferritinemia(>2000 ng/ml), hypertriglyceridemia and high LDH.

  14. A severe dyspnea due to ARDS (Acute Respiratory Distress Syndrome) has leaded us to use the mechanical ventilation.

  15. A sternal puncture was done

  16. SP showed an hemophagocytic syndrome

  17. CD68 marker of macrophages

  18. Perls coloration+(Iron deposit)

  19. Immunophénotypage médullaire • Lignée myélomonocytaire • Lignée lymphoïde

  20. Immunophenotypage

  21. Auto-immune check-up was also done

  22. After 3 days of ventilation and iv methylprednisolone (500 mg bolus over 3 days), the patient status recovered successfully.

  23. ETIOLOGIES OF HEMOPHAGOCYTIC SYNDROME • Infections: • Virus: Herpes group • Bacteria: Mycobacteria • Parasites: Leishmania, Plasmodium • Cancer:non- Hodgkin lymphoma • Auto- immune disease: SLE, Still Disease, Juvenile arthritis • Drugs:anti- seizures, minocycline, glucopeptide, cotrimoxazole, … • Unkown • Larroche C and Mouthon L, Autoimmun Rev , 2004, 3: 69- 75

  24. Hemophagocytic syndrome can be induced by either Plasmodium falciparumor vivax malaria infectionOhno T et al. Int J Hematol. 1996 Oct;64(3-4):263-6. Park Ts et al. Am J Hematol. 2003 Oct;74(2):127-30 Pahwa R et al. Indian J PatholMicrobiol. 2004 Jul;47(3):348-50

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