Leonor Cardoso1, Catarina Duarte2, Cristina Camilo2, Leonor Boto2, José Gonçalo Marques3.
1Department of Paediatrics, ULS da Cova da Beira, Covilhã, Portugal,
2Paediatric Intensive Care Unit, Department of Paediatrics, Hospital de Santa Maria - ULSSM, Lisbon, Portugal,
3Paediatric Unit of Infectious Diseases and Immunodeficiency, Department of Paediatrics, Hospital Santa Maria - ULSSM, Lisbon, Portugal.
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Abstract
Infection-associated secondary hemophagocytic lymphohistiocytosis (sHLH) is a potentially life-threatening hyperinflammatory condition, rarely associated with malaria. We present a case of sHLH triggered by P. falciparum, which was also complicated by acute kidney injury (AKI) and late onset pancreatitis, following intravenous artesunate.
Male adolescent with known sickle cell disease, who presented to the paediatric intensive care unit due to P. falciparum infection with low grade parasitemia (1%), shock and multisystem failure. Empirical treatment with ceftriaxone and clindamycin was started on admission, and intravenous artesunate was administered, with rapid clearance of malaria parasites. The severity of multisystem involvement led to investigation of sHLH, which was con?rmed (ferritin 136 791 ng/mL, CD25 16 000 pg/mL). Treatment with high dose dexamethasone led to a rapid improvement. On day 5, artesunate was stopped due to acute kidney injury with severe polyuria and mild elevation of pancreatic enzymes. The patient was transferred to the ward on day 10, and discharged home on day 20.
A severe clinical course of malaria with low parasitemia should raise the suspicion of sHLH. Prompt treatment of both the infectious trigger and the hyperin?ammation allowed for a good outcome. High dose dexamethasone alone may be sufficient in this setting. Our case also illustrates potential, although rare, toxicities of intravenous (IV) artesunate therapy, underscoring the need for continuous monitoring, as well as prompt antimalarial de-escalation to minimize iatrogenic effects.
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