背景:青蒿素后延迟溶血(PADH)是接受青蒿素为基础的联合治疗(ACT)后从严重疟疾中恢复的患者的严重并发症,包括蒿甲醚-本特林。在日本,在世界卫生组织(WHO)严重疟疾指南推荐的抗疟药中,葡萄糖酸奎宁静脉注射仅在29家指定医院提供,无法静脉注射青蒿琥酯。因此,偶尔口服蒿甲醚-本美曲碱作为替代药物,即使这可能是一种次优的治疗方法。在像日本这样的非地方病环境中,缺乏对疟疾和副作用的了解,例如由ACT引起的青蒿素后延迟溶血,可能会产生严重的后果。像我们的病人一样,在怀孕初期成为初产妇是严重疟疾的严重危险因素,必须仔细监测。
方法:本报告描述了一例严重的输入性恶性疟原虫疟疾,并伴有胎儿丢失和长期贫血,需要频繁输血.该患者是一名30岁前健康怀孕的日本女性。她从尼日利亚返回后2天出现高烧。患者符合世卫组织的严重疟疾标准。抵达后,腹部超声检查偶然发现胎龄5周的胎儿在子宫内心跳。鉴于她的怀孕和疾病的严重程度,她以负荷剂量静脉注射奎宁16mg/kg.然而,由于频繁呕吐和QTc延长,第二剂奎宁未给药.我们开始口服蒿甲醚-本美曲碱治疗,第4天通过显微镜观察证实寄生虫血症的清除。入院后第6天注意到流产。此外,患者再次发烧至39°C,从第14天到第22天,患者因PADH需要多次输血。在第40天,由于血红蛋白水平超过10g/dL,停止随访。
结论:在ACT治疗后从严重疟疾中恢复的患者中,强烈建议监测血红蛋白水平至少一个月,以便及时识别PADH.前往疟疾流行国家的旅行者,尤其是primigravida女性,应提供有关感染风险和预防的充分信息。
BACKGROUND: Post-artemisinin delayed hemolysis (PADH) is a serious complication in patients who recover from severe malaria after receiving artemisinin-based combined therapy (ACT), including artemether-lumefantrine. In Japan, among the antimalarial drugs recommended by the World Health Organization (WHO) guideline for severe malaria, intravenous quinine gluconate is available only in 29 designated hospitals, and intravenous artesunate is unavailable. Therefore, oral artemether-lumefantrine is occasionally administered as an alternative, even though it may be a suboptimal treatment. In non-endemic settings like Japan, a lack of knowledge of malaria and the side effects, such as post-artemisinin delayed hemolysis caused by the ACT, can have critical consequences. Like our patient, being a primigravida in the early stages of pregnancy is a serious risk factor for severe malaria and must be carefully monitored.
METHODS: This report describes a severe case of imported Plasmodium falciparum malaria complicated by fetal loss and prolonged anemia, requiring frequent blood transfusions. The patient was a previously healthy pregnant Japanese female in her 30 s. She developed a high fever 2 days after returning from Nigeria. The patient fulfilled the severe malaria criteria by WHO. On arrival, an abdominal ultrasound incidentally revealed a fetus of 5 week gestational age with a heartbeat in the uterus. Given her pregnancy and the severity of the disease, she was administered intravenous quinine 16 mg/kg as a loading dose. However, the second dose of quinine was not administered due to frequent vomiting and QTc prolongation. We initiated treatment with oral artemether-lumefantrine, and clearance of parasitemia was confirmed by microscopic observation on day 4. Miscarriage was noted on day 6 after admission. Moreover, the patient became feverish again up to 39 °C, and from days 14 to 22, the patient required multiple blood transfusions due to PADH. On day 40, follow-up was discontinued as the hemoglobin level exceeded 10 g/dL.
CONCLUSIONS: In patients who recover from severe malaria after ACT treatment, monitoring the hemoglobin level for at least a month is strongly recommended for prompt identification of PADH. Travelers to malaria-endemic countries, especially primigravida women, should be provided with adequate information on the risk and prevention of infection.