Algid malaria treated with early goal-directed therapy

Severe malaria complicated by circulatory shock is known as algid malaria. Cases of severe imported malaria are seen increasingly frequently in emergency departments in the United States, Europe, and other locales. The optimal volume resuscitation strategy for patients with severe malaria is not well-defined. A 20-year-old woman, who immigrated 2 weeks ago from Niger, Africa, presented to the emergency department of an urban teaching hospital with fever, hypotension, and malaise. She was resuscitated with 5.5 L of normal saline solution and norepinephrine. Thin blood smear demonstrated Plasmodium falciparum with parasitemia of 10% to 15%. She had rapid reversal of circulatory shock, cleared her parasitemia in less than 48 hours with antimalarial therapy, and was discharged home on hospital day 6 in good condition. The optimal resuscitation strategy for algid malaria is unknown, and volume restriction has been advocated as a means to prevent life-threatening cerebral and pulmonary edema. Although not identical, the late inflammatory response in severe malaria leading to capillary permeability shares many similarities with the immunologic response in bacterial sepsis. Our case report discusses a patient with severe imported malaria complicated by shock, successfully managed with large-volume fluid resuscitation, hemodynamic optimization, early antimalarial agents, and broad-spectrum antibiotics. This report questions the strategy of cautious fluid resuscitation in algid malaria and suggests that case series comparing goal-directed resuscitation to historic controls along with prospective multicenter controlled trials should be conducted to determine the best fluid resuscitation strategy.