Severe malaria: a micro vessel disease
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IMAGING IN INTENSIVE CARE MEDICINE
Severe malaria: a micro vessel disease Luca Bettini and Christophe Le Terrier* © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
Nine days after returning from Guinea, a 82-year-old woman, without medical history, was admitted to intensive care unit with coma and hypothermia. Malaria was diagnosed by peripheral drop smear (Plasmodium falciparum), with 25% parasitemia. An intravenous loading dose of artesunate was administered upon admission. On day two, parasitemia dropped to 0.2% and she developed symmetrical bilateral peripheral gangrenous lesions (Fig. 1A) related to disseminated intravascular coagulation, a rare condition in severe malaria. Brain CT scan was normal on admission but shows cerebral edema without microhemorrhages on day 3. On day 8, brain magnetic resonance imaging (MRI) revealed extensive diffuse symmetrical petechial hemorrhages throughout
*Correspondence: [email protected] Division of Intensive Care Medicine, Geneva University Hospitals, 4 rue Gabrielle‑Perret‑Gentil, 1205 Geneva, Switzerland
the gray-white matter junction, corpus callosum, internal capsules, basal ganglia, brainstem and cerebellum in the susceptibility weighted images (SWI) (Fig. 1B, Online video 1). The lesions were not detected in T1 and T2 sequences (Fig. 1C). Diffusion weighted images (DWI/ ADC maps) suggest a vasogenic edema (Fig. 1D). Diffuse microbleeding is not pathognomonic for a cerebral Plasmodium falciparum infection, yet the clinical context and the linear subcortical distribution of microbleeds, affecting the central gray matter structures and brainstem, suggest diffuse venous microvascular obstruction by sequestration of infected erythrocytes, a pathophysiological feature of cerebral malaria. Despite 2 weeks of treatment, the patient died.
Fig. 1 A Peripheral gangrene. B Brain axial 1.5 T MRI, SWI (susceptibility weighted imaging). Extensive bilateral microbleeds, represented by lacunar low signal intensity (black), are illustrated along the regions of the venules of both the superficial and deep venous systems corresponding to areas of parasite sequestration. C Brain axial 1.5 T MRI, T1 and T2 FLAIR (Fluid Attenuated Inversion Recovery). Microbleeds are not detected in both T1 and T2 FLAIR sequences. The T2 FLAIR sequence shows a diffuse increased signal of white matter suggesting cerebral edema. D Brain axial 1.5 T MRI, DWI (Diffusion Weighted Image, b value 1000 s/mm2) and ADC (Apparent Diffusion Coefficient) map sequences. DWI did not show any signal abnormality, but ADC map shows increased signal intensity of white matter. These sequences are consistent with vasogenic edema
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00134-020-06160 -w) contains supplementary material, which is available to authorized users. Acknowledgements We thank Prof. Vargas-Gomez for helping us with the interpretation of the radiological images. Author contributions LB wrote the article. CLT reviewed the article a
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