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Clinically uncomplicated Plasmodium falciparum malaria with high schizontaemia: a case report.

Lwin KM, Ashley EA, Proux S, Silamut K, Nosten F, McGready R - Malar. J. (2008)

Bottom Line: In low transmission areas or in non-immune travelers the presence of schizonts in the peripheral circulation is an indication for close patient supervision.In this case, an unusually high schizont count in a clinically uncomplicated patient was indicative of potential deterioration.Prompt treatment with intravenous artesunate is likely to have been responsible for the good clinical outcome in this case.

View Article: PubMed Central - HTML - PubMed

Affiliation: Shoklo Malaria Research Unit, Mae Sot, Tak, 63110, Thailand. drkhin_mg_lwin@shoklo-unit.com

ABSTRACT

Background: The treatment options for acute Plasmodium falciparum malaria are based on the clinician classifying the patient as uncomplicated or severe according to the clinical and parasitological findings. This process is not always straightforward.

Case presentation: An adult male presented to a clinic on the western border of Thailand with a physical examination and P. falciparum trophozoite count (1.2% of infected red blood cells, IRBC) from malaria blood smear, consistent with a diagnosis of uncomplicated P. falciparum infection. However, the physician on duty treated the patient for severe malaria based on the reported P. falciparum schizont count, which was very high (0.3% IRBC), noticeably in relation to the trophozoite count and schizont:trophozoite ratio 0.25:1. On intravenous artesunate, the patient deteriorated clinically in the first 24 hours. The trophozoite count increased from 1.2% IRBC at baseline to 20.5% IRBC 18 hours following the start of treatment. By day three, the patient recovered and was discharged on day seven having completed a seven-day treatment with artesunate and mefloquine.

Conclusion: The malaria blood smear provides only a guide to the overall parasite biomass in the body, due to the ability of P. falciparum to sequester in the microvasculature. In severe malaria, high schizont counts are associated with worse prognosis. In low transmission areas or in non-immune travelers the presence of schizonts in the peripheral circulation is an indication for close patient supervision. In this case, an unusually high schizont count in a clinically uncomplicated patient was indicative of potential deterioration. Prompt treatment with intravenous artesunate is likely to have been responsible for the good clinical outcome in this case.

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Thick blood film of patient on admission demonstrating significant presence of schizonts compared with trophozoites (oil immersion × 1000).
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Figure 1: Thick blood film of patient on admission demonstrating significant presence of schizonts compared with trophozoites (oil immersion × 1000).

Mentions: At the outpatient department, a rapid diagnostic test (Paracheck®Pf) result was strongly positive and, consequently, a malaria blood smear was taken. The malaria smear result (12:20 hrs) was Plasmodium falciparum trophozoites 12/1,000 RBC (equivalent to a parasitaemia of 51,245/μL (or 1.2% IRBC). Plasmodium falciparum schizonts were present on the slide and the count was high: 3/1,000 RBC (equivalent to a schizontaemia of 12,811/μL or 0.3% IRBC). Plasmodium vivax trophozoites were also noted at low density: 8/500 White Blood Cells (WBC) (or a parasitaemia of 128/μL). Scarce malaria pigment was observed in < 1% of polymorphonuclear leucocytes (neutrophils) (Figure 1). On admission his capillary blood haematocrit (HCT) was 34% and blood glucose 102 mg/dL.


Clinically uncomplicated Plasmodium falciparum malaria with high schizontaemia: a case report.

Lwin KM, Ashley EA, Proux S, Silamut K, Nosten F, McGready R - Malar. J. (2008)

Thick blood film of patient on admission demonstrating significant presence of schizonts compared with trophozoites (oil immersion × 1000).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2365953&req=5

Figure 1: Thick blood film of patient on admission demonstrating significant presence of schizonts compared with trophozoites (oil immersion × 1000).
Mentions: At the outpatient department, a rapid diagnostic test (Paracheck®Pf) result was strongly positive and, consequently, a malaria blood smear was taken. The malaria smear result (12:20 hrs) was Plasmodium falciparum trophozoites 12/1,000 RBC (equivalent to a parasitaemia of 51,245/μL (or 1.2% IRBC). Plasmodium falciparum schizonts were present on the slide and the count was high: 3/1,000 RBC (equivalent to a schizontaemia of 12,811/μL or 0.3% IRBC). Plasmodium vivax trophozoites were also noted at low density: 8/500 White Blood Cells (WBC) (or a parasitaemia of 128/μL). Scarce malaria pigment was observed in < 1% of polymorphonuclear leucocytes (neutrophils) (Figure 1). On admission his capillary blood haematocrit (HCT) was 34% and blood glucose 102 mg/dL.

Bottom Line: In low transmission areas or in non-immune travelers the presence of schizonts in the peripheral circulation is an indication for close patient supervision.In this case, an unusually high schizont count in a clinically uncomplicated patient was indicative of potential deterioration.Prompt treatment with intravenous artesunate is likely to have been responsible for the good clinical outcome in this case.

View Article: PubMed Central - HTML - PubMed

Affiliation: Shoklo Malaria Research Unit, Mae Sot, Tak, 63110, Thailand. drkhin_mg_lwin@shoklo-unit.com

ABSTRACT

Background: The treatment options for acute Plasmodium falciparum malaria are based on the clinician classifying the patient as uncomplicated or severe according to the clinical and parasitological findings. This process is not always straightforward.

Case presentation: An adult male presented to a clinic on the western border of Thailand with a physical examination and P. falciparum trophozoite count (1.2% of infected red blood cells, IRBC) from malaria blood smear, consistent with a diagnosis of uncomplicated P. falciparum infection. However, the physician on duty treated the patient for severe malaria based on the reported P. falciparum schizont count, which was very high (0.3% IRBC), noticeably in relation to the trophozoite count and schizont:trophozoite ratio 0.25:1. On intravenous artesunate, the patient deteriorated clinically in the first 24 hours. The trophozoite count increased from 1.2% IRBC at baseline to 20.5% IRBC 18 hours following the start of treatment. By day three, the patient recovered and was discharged on day seven having completed a seven-day treatment with artesunate and mefloquine.

Conclusion: The malaria blood smear provides only a guide to the overall parasite biomass in the body, due to the ability of P. falciparum to sequester in the microvasculature. In severe malaria, high schizont counts are associated with worse prognosis. In low transmission areas or in non-immune travelers the presence of schizonts in the peripheral circulation is an indication for close patient supervision. In this case, an unusually high schizont count in a clinically uncomplicated patient was indicative of potential deterioration. Prompt treatment with intravenous artesunate is likely to have been responsible for the good clinical outcome in this case.

Show MeSH
Related in: MedlinePlus