Severe Imported Plasmodium Falciparum Malaria: Report of Two Cases

嚴重的境外移入惡性瘧疾：兩個病例報告

蔡子修(Tzu-Hsiu Tsai) ； 施金元(Jin-Yuan Shih) ； 楊泮池(Pan-Chyr Yang)

《胸腔醫學》 19卷1期 (2004/02) Pp. 37-43

摘要

瘧疾主要見於熱帶地區。由於有越來越多的人至熱帶地區旅遊，境外移入的瘧疾病例也逐漸增加。瘧疾的臨床表現通常不具特異性，但嚴重的瘧疾感染，卻常造成各種併發症，對許多不具免疫力的病患造成相當程度的死亡威脅。這些嚴重的瘧疾感染，絕大多數都是由惡性瘧疾原蟲所造成。在此我們報告兩個境外移入的惡性瘧疾感染產生嚴重併發症的病例。第一個病例是一位由西非奈及利亞回國的六十五歲男性。另一位則是至南非及莫三比克旅遊的三十七歲男性。兩個病例都被發現在血液中有明顯的惡性瘧疾原蟲，雖然在住院的過程中經過了抗瘧疾藥物的治療，使得血液中被瘧疾原蟲感染的紅血球比例減少，這兩個病例卻仍然發生嚴重併發症，包括意識改變、肺水腫、急性腎衰竭、肝功能障礙、瀰漫性血管內凝血障礙、低血糖、及休克狀態等。血行動力檢查顯示其肺水腫應與肺部微小血管之滲漏有關。兩個病例在持續使用抗瘧疾藥物及包括機械性呼吸支持、血液透析、與其他重症加護的照顧措施下逐漸康復。由這兩個病例來看，對有相關旅遊史的病患保持高度的警覺才能早期診斷瘧疾。對嚴重的惡性瘧疾感染，除了有效的抗瘧疾藥物治療外，也往往需要重症加護單位嚴密的監控及適當的支持性療法。

關鍵字

瘧疾 ； 惡性瘧疾原蟲 ； 非心因性肺水腫

並列摘要

Although malaria is mainly seen in the tropics, imported cases of malaria increase as more people travel to endemic areas. The manifestations are generally nonspecific, but severe and complicated malaria, mostly attributed to Plasmodium falciparum, can result in substantial fatality in patients without clinical immunity. In this report, we present two cases of complicated imported falciparum malaria. The first case herein is of a 65-year-old man who had returned from Nigeria, West Africa, without malaria prophylaxis. The other is of a 37-year-old man who had traveled to South Africa and Mozambique. Significant falciparum parasitemia had been identified at presentation in both cases. Severe complications, including cerebral malaria, pulmonary edema, acute renal failure, disseminated intravascular coagulation, hepatic dysfunction, hypoglycemia, and shock, developed later in the course of hospitalization despite effective antimalarial chemotherapy with gradually resolving parasitemia. The hemodynamics measurement indicated that an increased pulmonary capillary leak might have been the cause of the pulmonary edema. Mechanical respiratory support, hemodialysis, and other intensive-care measures were needed. Both patients recovered after continuing antimalarial drugs and ancillary treatments in the intensive care unit. We conclude that a high degree of suspicion is important for early diagnosis of malaria in people with a relevant travel history. In addition to effective antimalarial drugs, close monitoring and adequate supportive treatment in an intensive care unit are usually mandatory for patients with severe falciparum malaria infection.

並列關鍵字

malaria ； Plasmodium falciparum ； non-cardiogenic lung edema