After being hospitalized for 16 days, patient DS was discharged with prescriptions to treat malaria and HIV. DS, a 53-year-old man returning from Burkina Faso, presented with nausea, vomiting, headache, and diarrhea. He was diagnosed with malaria after Plasmodium falciparum and P. vivax were seen on blood smear. DS developed malaria-associated acute respiratory distress syndrome and required ventilator support for 10 days. He recovered and was discharged on antimalarial and antiretroviral medications.

1. After day 16, DS recovered from and was discharged with
prescriptions for ferrous sulfate 325 mg PO daily, ascorbic acid
500 mg PO daily, and Folamin® one tab PO daily (all for 15
days) in addition to emtricitabine/rilpiverine/tenofovir)
(Complera®) 200/25/300 mg one tab PO once daily.
HOSPITAL COURSE cont.INITIAL PRESENTATION
HOSPITAL COURSE
DISCUSSION
Patient DS, a 53-year-old man returning from a three month
trip to Burkina Faso, presented to the Englewood Hospital and
Medical Center (EHMC) emergency department with a five day
history of nausea, vomiting, headache, and diarrhea with chills.
He had a prior diagnosis of human immunodeficiency virus
(HIV) (unknown at admission) and an unnamed sexually
transmitted infection (STI) at age 21. A review of systems was
significant for right upper quadrant pain. The patient had no
known drug allergies and an unremarkable family history.
EBOLA ACTION PLAN
• Developed during Oct 2014 and fully approved by Feb 2015
• Included the following elements:
– Pre-hospital/ED screening algorithm for travel or
contact exposure and symptoms
– Established information network to NJ Dept of Health
– Training on donning and doffing level C personal
protective equipment (PPE)
– Decontamination protocol for EMS personnel
– Cleaning and disinfection guidelines for surfaces,
linens, and objects contacting the patient
• Provided appropriate screening procedures to effectively
rule out EVD from differential diagnosis when appropriate
• Earlier existence would have alleviated concerns for EVD in
this patient
Author Contact Information
Jimmy Gonzalez, Pharm.D.
1 RWJ Place
New Brunswick NJ 08901
Phone: (732)-937-8842
Jimmy.Gonzalez@rwjuh.edu
Disclosures
Authors of this presentation have the following to disclose
concerning possible financial or personal relationships with
commercial entities that may have a direct or indirect interest
in the subject matter of this presentation:
Jimmy Gonzalez – Nothing to disclose
Deirdre Minihan – Nothing to disclose
Joseph E. Cruz – Nothing to disclose
DIFFERENTIAL DIAGNOSIS
• Malaria
• Ebola virus disease
• Marburg virus
• Both Plasmodium falciparum and P. vivax were observed in
DS’s blood smear
• The patient’s baseline parasitemia was 3.8%
• Parasitemia responded to antimicrobial therapy
• Quinidine gluconate
– Loading dose (LD): 1600 mg IV once
– Maintenance dose (MD): 800 mg IV q8h
• Doxycycline 100 mg IV q12h
• Parasitemia cleared by day 4 of hospitalization
Recognition and management of severe malarial infection
during the 2014 West African Ebola outbreak
Jimmy Gonzalez, Pharm.D.1; Deirdre Minihan, Pharm.D., BCPS2; Joseph E. Cruz, Pharm.D., BCPS1,2;
Jeffrey Nemeth, BSP, Pharm.D., MPA2
1Ernest Mario School of Pharmacy, Rutgers the State University of New Jersey, Piscataway NJ
2Englewood Hospital and Medical Center, Department of Pharmacy, Englewood NJ
Vital signs Laboratory values
Blood pressure (BP):
97/56 mmHg
White blood cell count (WBC):
3.6 x 103 cells/mm3
Heart rate (HR):
114 beats per minute
Platelet count (PLT):
18,000
Respiratory rate (RR):
18 breaths per minute
Hemoglobin (Hgb):
13.2 g/dL
Temperature (Temp): 97.6° F
(Reported 104° F at home)
Total bilirubin (T.bili):
3.3 mg/dL
Malaria Ebola Virus Disease Patient’s Symptoms
Fever Fever Fever
Headache Severe headache Headache
Chills Myalgias Chills
Weakness Weakness Nausea
Fatigue Diarrhea Diarrhea
Vomiting Vomiting Vomiting
Abdominal pain Abdominal pain Abdominal pain
Myalgias Fatigue
Malaise Unexplained hemorrhage
Incubation: 7-40 days
(avg 9-18 days)
Onset: 2-21 days
(average 8-10 days)
While cases of malaria are uncommon at our small community
hospital, swift diagnosis of this disease was imperative for
appropriate treatment. At the time of diagnosis, EVD had not
yet reached the US; however, the WHO had already declared
an international emergency. Rapid, accurate recognition of
EVD relative to other more common (but similarly presenting
illnesses) was a key pearl gleaned from our experience with
patient DS.
• Typhoid fever
• Traveler’s diarrhea
• Meningococcal disease
The hospital course was complicated by a desaturation event
on day 3 that evolved into bilateral pulmonary infiltrates
requiring mechanical ventilation from day 3 until 13.
The patient developed an uncommon complication of malaria-
--malarial acute respiratory distress syndrome (MA-ARDS).
Parasitized erythrocytes lead to hemolysis, explaining the
observed anemia and hyperbilirubinemia; however, these cells
may also have reduced deformability, adhere to alveolar
capillaries, or precipitate inflammatory reactions to the
parasites locally in the lungs. MA-ARDS is associated with a
poor prognosis (80% lethality) and has a prevalence of 2-20%
in severe malarial infections.
No standardized regimen exists for MA-ARDS, but often
supportive care such as low tidal volume ventilation with low-
moderate PEEP, neutral or negative fluid balance, and high
dose steroids are offered. DS was given high dose
methylprednisolone IV (125 mg IVP q6h) for four days followed
by a rapid taper and discontinuation after switch to oral
prednisone.
Table 1. Patient vital signs and laboratory values at presentation
0
5
10
15
20
25
30
35
40
45
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Day of Hospitalization
Table 2. Comparison of malarial and EVD symptoms and onset period
Figure 2. CDC-recommended emergency department evaluation algorithm
Figure 1. Variation of hemostatic parameters and WBC over hospitalization
WBC (x 103 cells/mm3)
Hgb (g/dL)
HCT (%) REFERENCES
1. Van de Steen PE, Deroost K, Deckers J, et al. Pathogenesis of malaria-associated acute respiratory distress syndrome.
Trends in Parasitology 2013;29:346-58.
2. Cheng MP, Yansouni, CP. Management of severe malaria in the intensive care unit. Crit Care Clin 2013;29:865-85.
3. Griffith KS, Lewis LS, Mali S, et al. Treatment of malaria in the United States: a systematic review. JAMA 2007;297:2264-
77.
4. Centers for Disease Control and Prevention. Ebola (ebola virus disease) [internet]. [Updated 2015 Nov 11; cited 2015 Nov
26]. Available from: http://www.cdc.gov/vhf/ebola/.
Identify exposure history
Identify signs and symptoms
of EVD
Continue triage as usual
1. Continue triage as usual
2. Notify health department
3. Monitor until 21 window closes
Isolate and determine PPE need
Immediately inform:
1. Hospital infection control program
2. Health department
YES
YES
NO
NO
Adapted from: CDC. Identify, isolate, inform: Ambulatory care evaluation of patients with possible Ebola virus disease. 2015 Feb.