Reversal of Life-Threatening Vascular Occlusion by Apheresis in Fulminating Plasmodium Falciparum Malaria

Abstract

Plasmodium falciparum parasitisation can result in a systemic inflammatory response characterised by profound neurologic complications, renal failure, adult respiratory distress syndrome and disseminated intravascular coagulation with high morbidity and mortality. Complete obstruction to medium sized arteries seems not to have been reported before while the role of sequential whole blood and plasma exchange may be an under-utilised intervention that is life-saving in selected cases.

A 25 year old patient was referred with mental confusion, rapidly deteriorating vision, hypotensive and oliguric, massive generalised oedema compressing muscles leading to rhabdomyolysis and impending gangrene of both lower limbs. 1,555 mL of whole blood was exchanged in the cell separator to reverse the haemoglobin of 35g/L, remove parasitised and effete red cells while simultaneously correcting hypovolaemia. Thereafter 4,000mL of fresh frozen plasma was similarly exchanged and 3 × 10¹¹ platelets given to treat the advanced disseminated intravascular coagulation. Anti-malarial therapy was continued with quinine sulphate and doxycycline for the chloroquin-resistant parasites.

The tense swelling of the limbs gradually resolved, thereby avoiding fasciotomies, arterial occlusion reversed and microvascular perfusion was re-established with resolution of all symptoms. Tissue loss was eventually limited to fore foot amputation on the left. The patient has been physically and psychologically rehabilitated and discharged after six weeks in hospital.

Malaria, when associated with multiple organ failure, is frequently fatal. Where appropriate, complications—due to vascular occlusion—can be promptly reversed with suitable apheresis. This practical approach is relatively inexpensive and should be available in all centres responsible for managing such patients.

Keywords:

• Malaria
• chloroquin-resistance
• P. falciparum
• multiple organ failure
• whole blood exchange
• plasmapheresis