Background

Use of RBC exchange in severe malaria is unclear from current literature. RBC exchange in severely ill patients with hyperparasitemia (i.e. >10%) appears to ‘improve blood rheological properties, capillary perfusion and microcirculatory flow’.

Objectives

Review current guidance for RBC exchange transfusion in severe paediatric malaria.

Methods

Case presentation and review of published guidance.

Results

A 19 month old Nigerian infant was admitted extremely unwell, tachypnoeic, tachycardic and encephalopathic, following focal seizure.

Initial results confirmed profound metabolic acidosis (pH 6.86), high lactate (21mmol/l), normal blood sugar (5.7mmol), anaemia (haemoglobin 54g/dl), thrombocytopenia (platelet 16x10⁹/l), and coagulopathy with hepatorenal impairment. Peripheral blood smear showed plasmodium falciparum with 35% parasitaemia. CT head was normal with typical retinal haemorrhages on fundoscopy.

Following PICU admission he commenced intravenous artesunate and broad spectrum antibiotics.

Due to disease severity, after multi agency discussion with UK colleagues, he received an automated RBC exchange transfusion with good effect. He completed 5 days of IV artesunate and 6 doses of Artemether with Lumefantrine.

At discharge, his MRI Brain and neurological examination was normal.

The CDC recommends that exchange transfusion be strongly considered in hyperparasitaemia if complications such as cerebral malaria, pulmonary oedema, or renal compromise exist. Automated RBC exchange is safe and well tolerated and has advantages of retaining plasma with antimalarial drugs, clotting factors and platelets.

Conclusion

This case highlights good response to exchange transfusion in addition to artesunate. We suggest the theoretical advantages of RBC exchange transfusion should merit consideration in extremely ill patients with high parasite load, in a resource rich setting. .