SEVERE AND COMPLICATED MALARIA - REPORT OF 6 CASES

Six patients with severe and complicated falciparum malaria (6.7 +/- 2 .7 WHO criteria) were admitted to our Intensive Care Unit. All patient s acquired the disease while travelling in tropical Africa without app ropriate chemoprophylaxis. The clinical manifestations included hyperp yrexia (all patients), chills (4), sweating (2), asthenia (3), anorexi a (2), headache (1), arthralgias (1), vomiting (4), diarrhoea or abdom inal discomfort (3), jaundice (2) and disturbances of consciousness (4 ). All patients had anemia, thrombocytopenia, hyponatremia, hypoprotei nemia, hypoalbuminemia, hypocalcemia and acute renal failure, in one c ase associated with anuria. A low grade parasitemia was observed in tw o patients and a high grade parasitemia (20%-58% of erythrocytes) in f our. Exchange transfusion was performed only in high parasitemic patie nts and ail of them survived. All patients were treated with quinine, a sulfonamide and pyrimethamine. Additionally, five patients received oxytetracycline, doxycycline or clindamycin. Three patients required h emodyalisis. Five patients had delirium, coma or seizures. All patient s had at least one sign of hepatic impairment: liver enlargement, jaun dice or increased bilirubin or aminotransferase levels. Two patients h ad spleen enlargement. Laboratory findings suggested disseminated intr avascular coagulation in four patients. Four patients developed pulmon ary changes and three of them required mechanical ventilation. A Swan- Ganz catheter was placed in four patients. In three of them (two with pulmonary edema) the pulmonary capillary wedge pressure was initially increased, which suggested a cardiogenic or hypervolemia mechanism, bu t soon returned to normal level. One patient with low grade parasitemi a died because of adult respiratory distress syndrome after 18 days. I n our series, the degree of parasitemia was not related to the severit y of the disease.