熱帯熱，三日熱マラリア混合重症感染の１例　ａｒｔｅｍｅｔｈｅｒによる治療経験

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  • A case of severe mixed Plasmodium falciparum and P. vivax infection successfully treated with artemether.
  • ネッタイ ネツ ミッカネツ マラリア コンゴウ ジュウショウ カンセン ノ 1
  • artemetherによる治療経験

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As the number of individuals traveling to malaria endemic countries increases, many patients with malaria are increasingly being observed in Japan. Nevertheless malaria is liable to be misdiagnosed, incorrectly treated, and a severe course is thus not unusual. However there are hardly any reports describing severe malaria in a Japanese patient due to mixed P.f and P. v. infection. We report a case of severe malaria due to mixed P.f. and P.v.infection. The effectiveness of the new antimalarial drug, artemether, in the treatment of this case of severe malaria is also documented.<BR>A Japanese 31-year-old male was admitted to Kitasato University Hospital because of fever, diarrhea, and circulatory collapse. The history of this patient is that one week after his return from a 9 day visit to Indonesia, during which he had weekly chloroquine prophyraxis, developed fever and chills. He visited a hospital where he was treated for a common cold. High fever was sustained and accompanied by watery diarrhea. On admission to our hospital, his temparature was 40°C. The patient was lethargic but fully oriented and responsive. He was dehydrated and perfusing poorly. Physical examination revealed jaundice, hepatomegaly, and diffuse tenderness from the right costal margin to the epigastrium. P.f. and P. v. were detected from a blood smear (12% and 0.7% parasitemia, respectively). Oral therapy with 600 mg quinine hydrochloride and 100 mg doxycycline was initiated. The next day, his fever was unalterd, diarrhea and severe oliguria were evident. P.f. parasitemia increased to 29%. Antimaralial therapy was changed to 250 mg quinine hydrochloride administered intravenously and fansimef, one tablet. Within 24 hr, he developed anuria and drowsiness. Cerebral malaria was suspected and hemodialysis was started. Treatment with quinine was replaced by artemether. Two hundred mg of artemether was administered as first dose intramusculary followed by 100 mg at interval of 12 hr, up to a total of 600 mg. Examination of blood smear indicated complete elimination of asexual stages of the parasite, within 38 hr after the onset of treatment with artemether. Thereafter, diuretic phase began and the patient made a complete recovery. Histopathology of a renal biopsy specimen showed tubular atrophy with interstitial lymphocytic infiltration, mild fibrosis and pigmented casts, all suggestive of tubular necrosis but no glomerular involvement. Thus acute tubular necrosis was considered as a cause of acute renal failure in this patient. To consolidate artemether therapy and eliminate possible recrudescence, treatment with mefloquine was initiated, at the dose of 500 mg a day orally for 2 days. On the day the patient was discharged, he was put on primaquine at the dose of 15 mg a day for 2 weeks. Forty-eight days later, despite the treatment given, he had fever and was diagnosed as a P. v. relapse case. Treatment with chloroquine and twice as much primaquine cleared parasitemia. Four months following this last treatment, the patient again had the symptom of fever and was treated this last treatment, the patient was again had the symptom of fever and was treated this time with halofantrine and primaquine. Treatment with primaquine for 2 weeks was followed by primaquine (45 mg) together with chloroquine (300 mg) once a week for 8 months. Serum anti-P.f. and P. v. IFAT titer profile of the patient over the entire course of his treatment confirmed the clinical course of the disease.<BR>The goal of the initial therapy of malaria is lowering the level of parasitemia as rapidly as possible under strict intensive care with monitoring of vital organ functions. Artemether was effective in achieving this goal even in this case of severe and complicated malaria due to mixed P.f. and P. v. infection.

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