7 - Case - Parasitic

Parasitic Infection
Slides prepared by Dr Sanjay Dhanuka, Dr Rakesh Nongthombam

Case Discussion
Case profile
• A 42-year-old male is planning a 2 month missionary trip to several countries in

West Africa.
What are the options for chemoprophylaxis?
• Malarone (atovaquone and proguanil),

• Doxycycline, or
• Mefloquine (safe in pregnancy)
• He opted for Doxycycline, however was not fully compliant due to
stomach upset with the same and stopped midway.
10 days after returning, he is referred from the emergency
department with fever, chills, rigor, and generalized weakness.
• He also complained of headache, muscle ache, fatigue and often
sweating
On examination,
• he is drowsy, icterus present
• temperature 39.2°C,
• heart rate 126 beats per minute,
• blood pressure 90/54 (60) mmHg,
• respiratory rate 30 breaths per minute
Laboratory investigations
1. CBC : Hb - 6.5 gm%, platelet count – 96000 , TLC – 17,000

2. LFT: Raised bilirubin, Increased ALT and AST.
3. S Creatinine and Blood urea nitrogen slightly increased.
4. Blood smear: ( thick and thin blood smear) malarial parasite
detected
5. Quantitative buffy coat (QBC) test: looking for different malarial
species awaited
• Diagnosis of malaria??
• 1- Peripheral smear – thick and thin
Yield only 30-35%
• 2- Rapid diagnostic tests

High negative predictive value
The blood smear shows Plasmodium Falciparum –
How do you manage ?
• Intravenous artesunate : DOC
loading dose : 2.4 mg/kg body weight over 5 minutes
• At 0 hours, 12 hours, 24 hours
then daily for maximum of 7 days
• Important to re-evaluate parasite index 4-h after the 3rd dose of IV artesunate. If
parasitic index >1% to continue IV. Can shift to oral if <1% and able to take orally.
• Intravenous fluid resuscitation with crystalloids
• Side effects –
Delayed hemolysis : 7-21 days (self limiting
• Check Hb at 14 days
Other option if Artesunate not available
• IV Quinine
Loading dose 20 mg /kg over 4 hours
• Then 10 mg/kg every 8 hours over 48 hours
• Or until patient can take oral medications
• Convert to oral Quinine 600 mg TDS

for 5-7 days
• S/E
Cinchonism (hearing loss, tinnitus, flushing, nausea)
Hyperinsulinemia – causing hypoglycemia – monitor blood sugars 1-2 hours
Risk of hypotension and dysrhthmias
• Add Doxycycline / Clindamycin to be combined with quinine

• Q- How is Quinine administered – What do you monitor?
• Give in a continuous infusion of 5% or 10% dextrose IV.

A total plasma level >8μg/ml,
• ECG monitoring –
QT interval >0.56 s, or QRS widening beyond 25% is indication for slowing of infusion rates.
• The development of arrhythmias or saline unresponsive hypotension, warrants treatment
stoppage.
• If patients remains in acute renal failure after 48 hrs of IV quinine therapy, the maintaince
dose should be reduced by one-third to half.
• What is parasitic index? What is its significance?
• The percentage of RBCs infected with the parasite is calculated as parasitic index.
• >5% of parasitemia – associated with worse prognosis.
Q- What is severe, complicated malaria ?
• Impaired consciousness/ seizure

• Hb< 8
• AKI
• Shock
• Hypoglycemia
• ARDS
• Spontaneous bleeding
• Acidosis (pH< 7.3)
• Parasitemia > 10%
Q- What are the poor prognostic indicators
Supportive treatment
• Oxygen support
• IV fluids as needed
• Monitor and treat hypoglycemia
• Blood transfusion
• Dialysis if AKI
• Possibility of bacterial co-infection in about 15% of adults with severe malaria. Hence if
patient is critically ill may be prudent to cover with a broad-spectrum antibiotic.
How will you monitor?
• Vitals
• Blood sugar – every 2 - 4 hourly
• Hb, platelet counts
• Creatinine
• Clotting
• Electrolytes
• Daily parasitic count/ index (fluctuates with life cycle of parasite)
Follow up
• ABG with special interest on Lactate level

• Blood culture
• Urine analysis
Prognosis
• The prognosis for parasitic sepsis depends on,

type and severity of the underlying parasitic infection,
Patient's overall health status, and
Timely diagnosis and appropriate treatment initiation.
In severe cases, parasitic sepsis can lead to multiorgan failure and can be life-threatening. Close
monitoring of the patient's clinical progress, serial laboratory tests, and imaging studies are
essential for evaluating treatment response and detecting any complications.
Thank you

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Parasitic Infection

Slides prepared by Dr Sanjay Dhanuka, Dr Rakesh Nongthombam

• A 42-year-old male is planning a 2 month missionary trip to several countries in

• Malarone (atovaquone and proguanil),

1. CBC : Hb - 6.5 gm%, platelet count – 96000 , TLC – 17,000

• 2- Rapid diagnostic tests

• Convert to oral Quinine 600 mg TDS

• Add Doxycycline / Clindamycin to be combined with quinine

• Give in a continuous infusion of 5% or 10% dextrose IV.

• Impaired consciousness/ seizure

• ABG with special interest on Lactate level

• The prognosis for parasitic sepsis depends on,

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