Role of Plasmapheresis in Management of Autoimmune Vasculitis Secondary to Severe Malaria

Abstract

INTRODUCTION: Severe malaria is a potentially fatal complication of infection with Plasmodium falciparum species. There is increased risk for its acquisition and complex presentation among travelers from non-endemic countries. CASE PRESENTATION: A 68-year-old Afro-Caribbean female with past medical history of hypertension, presented with altered mental status. She had recently traveled to Senegal but didn't take any malaria prophylaxis. One week before admission, patient developed subjective fevers and a flu-like prodrome, which culminated in signs of slurred speech and confusion. Medical attention was sought and CT-scan of head revealed the presence of a right temporal intraparenchymal hemorrhage. She was subsequently transferred to our institution for further management. On presentation she was febrile but hemodynamically stable. Patient had left sided hemiparesis and was oriented to person and place only.Anemia and severe thrombocytopenia were noted on routine CBC. Further review of the peripheral smear lead to the discovery of Plasmodium falciparum (2% parasitemia). Her creatinine was acutely elevated at 3.68 mg/dl. She was admitted to intensive care unit and therapy with intravenous quinidine and doxycycline was initiated in conjunction with Center for Disease Control (CDC) recommendations. Within 24 hours of ICU admission, she was intubated for worsening mental status. Parasitemia decreased to < 1%. MRI brain revealed multiple foci of infarction in a watershed distribution concerning for cerebral malaria versus cerebral vasculitis. Autoimmune workup came back positive for ANA, low C4, Anti-SSA, Anti-centromere antibodies. Patient was started on plasmapheresis as per rheumatology recommendation for autoimmune vasculitis secondary to parasitemia. Her renal failure and thrombocytopenia resolved after 3 cycles of plasmapheresis, however patient remained comatose eventually requiring tracheostomy. DISCUSSION: Patients with severe malaria have high morbidity and mortality. Plasmapheresis has been used as an effective therapy in the treatment of various forms of immune complex-mediated vasulitis. However its exact role in malaria induced vasculitis is unknown. Our patient's thrombocytopenia and renal failure resolved post plasmapheresis although neurological status failed to improve, suggesting delayed recognition of immune vasculitis and treatment. CONCLUSIONS: Autoimmune vasculitis secondary to severe malaria is a rare and under recognized entity (1). Degree of parasitemia doesn't necessarily correlate with the development of immune activation (2). Early recognition and treatment with plasmapheresis may improve neurological outcome.