Chloroquine-Resistant Plasmodium Falciparum Malaria in a Pregnant Woman
1997; King Faisal Specialist Hospital and Research Centre; Volume: 17; Issue: 2 Linguagem: Catalão
10.5144/0256-4947.1997.247
ISSN0975-4466
AutoresSyalini Manohar, A Baker, Anand Rao Pawar, Tunji Oridota,
Tópico(s)Hemoglobinopathies and Related Disorders
ResumoBrief ReportsChloroquine-Resistant Plasmodium Falciparum Malaria in a Pregnant Woman Syalini Manohar, MD Abdullah Baker, FACHARZT Anand Rao Pawar, and MD Tunji OridotaMRCOG, FWACS Syalini Manohar Address reprint requests and correspondence to Dr. Manohar: Laboratory Section, Al Yamamah Hospital, P.O. Box 17185, Riyadh 11484, Saudi Arabia. From the Section of the Laboratory, Al Yamamah Hospital, Riyadh Search for more papers by this author , Abdullah Baker From the Section of the Obstetrics and Gynecology, Al Yamamah Hospital, Riyadh Search for more papers by this author , Anand Rao Pawar From the Al Yamamah Hospital, Riyadh Search for more papers by this author , and Tunji Oridota From the Section of the Obstetrics and Gynecology, Al Yamamah Hospital, Riyadh Search for more papers by this author Published Online:24 Apr 2019https://doi.org/10.5144/0256-4947.1997.247SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionPregnant women have an increased prevalence of Plasmodium falciparum (P. falciparum) infection and parasitemias may be high.1 They are particularly prone to hypoglycemia, acute pulmonary edema, hemolytic anemia, fetal distress, premature labor and stillbirth.2 Although chloroquine is the treatment of choice in pregnant women, chloroquine-resistant strains of P. falciparum are spreading rapidly,3 and when a pregnant woman is infected with chloroquine-resistant P. falciparum, the alternative choice of drugs must consider potential adverse effects to the fetus and mother.4We report here the clinical presentation and management of a patient in the third trimester of pregnancy with chloroquine-resistant malaria, along with a brief review of the literature.CASE REPORTA 35-year-old Saudi female who was 28 weeks into her second pregnancy presented to the emergency room with fever, chills and rigors of four days' duration. She gave a history of having just returned from Gizan Province. She gave no past history of foreign travel, malaria prophylaxis or blood transfusion. Physical examination showed a temperature of 38°C and blood pressure of 100/70 mm/Hg. She was moderately pale but not jaundiced. The uterus was compatible with 28 weeks' gestation. The fetal heart was positive. There was moderate hepatosplenomegaly. The laboratory findings were as follows: leukocyte count 14x109/L with normal differential, hemoglobin 72 g/L, platelets 140x109/L. The peripheral blood film showed numerous ring-form trophozoites of P. falciparum. There were 8.2% parasitized red cells (Figure 1). Blood and urine cultures were negative. Other laboratory results were within normal limits.Figure 1. Peripheral blood film on admission, showing severe parasitemia (Wright's stain, 100x.)Download FigureThe patient was given chloroquine as per the standard regime. At the end of 48 hours, her temperature was 38°C and she continued to feel ill. Since the patient had no vomiting with chloroquine, it was assumed that enough chloroquine was absorbed. Some relevant investigations were repeated and the results were as follows: hemoglobin 60 g/L, platelets 80x109/L, peripheral blood film showed numerous ring forms and occasional gametocyte forms of P. falciparum. The parasitized red cells were up to 8.4% (Figure 2). However, no evidence of hemolysis was noted in the blood film. A diagnosis of chloroquine-resistant P. falciparum malaria was made and the resistance was graded as R III.5 Although parenteral chloroquine was discussed, it was felt that this trial would further delay effective management. Therefore, after a baseline estimation of random blood sugar (result: 6.0 mmol/L), the patient was given quinine hydrochloride 600 mg IV every eight hours, diluted in 300 mL of 5% dextrose over a period of four hours. Continuous electrocardiogram and vital sign monitoring was done. Random blood sugar was checked every four hours.Figure 2. Peripheral blood film, 48 hours after chloroquine therapy, showing persistence of high parasitemia (Wright's stain, 100x).Download FigureSix hours later, the patient delivered a live baby weighing 900 grams. Twelve hours after quinine was begun, the patient's temperature fell to 36.2°C. A peripheral blood film examination done at this time showed a marked decrease in the number of parasitized red cells (6.2%). The patient felt better, but her random blood sugar fell to 2 mmol/L and she developed mild tinnitus. Intravenous quinine was discontinued. The patient was placed on oral quinine along with tetracycline (since she was not breast-feeding). Two units of packed red cells were transfused. The patient was discharged three days later with a hemoglobin of 102 g/L. Her blood film at discharge showed no malarial parasite.The patient was seen again at the outpatient clinic at weekly intervals for one month after discharge. At all four visits she remained asymptomatic and her blood film showed no malarial parasite.DISCUSSIONIn nonendemic areas, P. falciparum malaria is an important cause of fetal death, low birth weight and spontaneous abortion.1 Pregnant women are prone to severe infection and are particularly vulnerable to developing high parasitemias with anemia, hypoglycemia and premature labor,3 all of which were seen in our patient. The increased morbidity and mortality of malaria in pregnancy may be due to an increase in serum Cortisol levels, causing loss of malarial immunity.6The choice of drugs in the treatment of P. falciparum malaria in pregnancy must consider potential adverse effects on the fetus.4 Although chloroquine is the treatment of choice in pregnant women, chloroquine-resistant strains may be encountered, as in our patient, and alternative modalities of treatment must be carefully planned. Efforts to quantitate parasitemia are useful in determining a baseline parasitemia from which response to treatment can be monitored. The parasite is counted as the number of parasitized red cells in 1000 red cells and is then expressed as a percentage, or converted to the number per microliter. If the parasitemia does not fall to 25% of the admission value within 48 hours, drug resistance should be suspected.3 Three degrees of resistance are recognized: R I resistance, where parasites disappear from the peripheral blood, but reappear by day 14; R II resistance, where parasitemia decreases to 25% or less of the pre-treatment level, but never completely disappears; and R III resistance, where there is little or no fall in parasitemia after chloroquine administration.5 Our patient's resistance was graded as R III.Therapy in chloroquine-resistant malaria has been a major concern since 1961, when these strains were first recognized. Fansidar, a fixed dose combination of sulphadoxine and pyrimethamine, can be used, but antifolate drugs can have teratogenic effects.4 Mefloquine, an oral 4-quinolinemethanol, approved by the FDA in 1989 for treatment of P. falciparum malaria, is uniformly schizonticidal in chloroquine-resistant malaria, but it is contraindicated in pregnancy.3 Halofantrine, an oral phenanthrenemethanol, is effective against chloroquine-resistant strains of P. falciparum, but clinical data is insufficient to permit its use in pregnant women.4In a situation like this, quinine seems to become the drug of choice.3 Quinine shows no increased teratogenic risk and no risk of premature labor; but in pregnancy, in particular, patients are at risk from quinine-induced hyperinsulinemia. When the risk of inadequately treated chloroquine-resistant malaria outweighs the risk of quinine therapy, this drug can be used.7The gap between the development of new antimalarials and of resistance to them seems to be narrowing and P. falciparum is highly resistant to chloroquine and sulfadoxine/pyrimethamine. It is also becoming resistant to quinine and even mefloquine. In such cases, two artemisin derivatives, artemether and artesunate, have been used.8 Azithromycin, a 15-membered ring macrolid, is being studied as an antimalarial agent, and investigators suggest that it may be ideal in treatment of resistant malaria on grounds of superior efficacy and lower toxicity; also, unlike the tetracyclines, it is not contraindicated in pregnant women.9ARTICLE REFERENCES:1. Bray RS, Anderson MJ. "Falciparum malaria and pregnancy" . Trans R Soc Trop Med Hyg. 1979; 73:427–31. Google Scholar2. Galbraith RM, Faulk WP, Galbraith GM, et al.. "The human materno-fetal relationship in malaria" . Trans R Soc Trop Med Hyg. 1980; 74:52–61. Google Scholar3. Plorde JJ, White NJ. Malaria. In: Wilson JD, Braunwald E, Isselbacker KJ, et al., editors. Harrison's Principles of Internal Medicine. 12th ed.New York: MacGraw Hill Inc, 1991:782–8. Google Scholar4. Wyler DJ. Plasmodium species (malaria). In: Mandell GL, Douglas RG, Bennett JE, editors. Principles and Practice of Infectious Diseases. 3rd ed.New York: Churchill Livingstone, 1990:2056–65. Google Scholar5. World Health Organization. 1973. Tech Rep Ser 529. Google Scholar6. Vleugels MPH, Eling WMC, Roland R, De Graaf R. "Cortisol and loss of malaria immunity in human pregnancy" . Brit J Obstet Gynaecol. 1987; 94:758–64. Google Scholar7. Looareesuwan S, Phillips RE, White NJ, et al.. "Quinine and severe falciparum malaria in late pregnancy" . Lancet. 1985; 2:4–7. Google Scholar8. Kwiatkowski D, Bate C. "Inhibition of tumor necrosis factor (TNF) by antimalarial drugs used in cerebral malaria" . Trans R Soc Trop Med Hyg. 1995; 52:159–61. Google Scholar9. Anderson SL, Ager A, McGreevy P, et al.. "Activity of azithromycin as a blood schizonticide against rodent and human plasmodia in vivo" . Am J Trop Med Hyg. 1995; 52:159–61. Google Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byOmar M, Malik G, Al-Amari O, Abdalla S and Moosa R (2019) The Rapid Manual ParaSight™-F Test for Diagnosing Plasmodium Falciparum Malaria in Saudi Arabia, Annals of Saudi Medicine , 19:2, (159-162), Online publication date: 1-Mar-1999.Al Arishi H, Al Hifzi I and Ishag Y (2019) Chloroquine-Resistant Plasmodium Falciparum Malaria in an Extremely Premature Infant, Annals of Saudi Medicine , 19:3, (245-247), Online publication date: 1-May-1999.Banzai S, Ayoola E, Sammani E, Rahim S, Subramaniam P, Gadour M and Jain A (2019) The Clinical Pattern and Complications of Severe Malaria in the Gizan Region of Saudi Arabia, Annals of Saudi Medicine , 19:4, (378-380), Online publication date: 1-Jul-1999.Alrajhi A and Frayha H (2019) Chloroquine-Resistant Plasmodium Falciparum: Is It Our Turn?, Annals of Saudi Medicine , 17:2, (151-153), Online publication date: 1-Mar-1997. Volume 17, Issue 2March 1997 Metrics History Received25 September 1995Accepted26 June 1996Published online24 April 2019 ACKNOWLEDGMENTWe thank Mr. Mohammed Al Hassan Merghani for his technical help.InformationCopyright © 1997, Annals of Saudi MedicinePDF download
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