MALARIA CASE STUDY

By Sarah Tinkle
Introduction to the problem
Malaria
- According to the CDC, Malaria is an infection with malaria parasites that can result in a wide
variety of symptoms ranging from absent to severe.

Severe Malaria
- According to the CDC occurs when infections are complicated by serious organ failures or
abnormalities in patients blood or metabolism.

- This can include Cerebral malaria, ARDS, low blood pressure, acute kidney injury,
hyperparasitemia, metabolic acidosis, hypoglycemia, and can even lead to death.
 22 year old female

Introduction to the Admitted with high fever,

body aches, and vomiting
subject
Recently returned from 8
week trip to Tanzania
Patient History
-Prior to admission patient had recently returned
from a trip to Africa, where she was finishing her
teaching degree.

-Patient spend 8 weeks in the country and suffered

from multiple mosquito bites while she was there.

-Patient was prescribed malaria prophylaxis and

had taken it while she was in Africa, but upon
returning she admitted to missing several doses,
and did not complete her prescribed treatment.

-No prior medical history other than a sexual

assault in 2018.
 ● The incubation period following an
infective bite from a mosquito can

Incubation period
vary anywhere from 7 to 30 days or
dormant for up to 1 year in the liver.

● Antimalarial drugs taken by travelers

can delay the appearance of malaria
symptoms by weeks to months after
the traveler has left the malaria area.
Initial Encounter: 6/7/19
-Patient admitted with fevers of 104, malaise,
fatigue, weakness, headaches and joint pain. Lab
reported malaria smear to be positive. Transferred
to MICU due to SOB and worsening renal
function.
-Patient has been placed on Airvo. Parasitemia was
2.4%. Patient had volume overload, hemolysis, and
uremic symptoms like nausea/vomiting. Patient
was anuric. Patient began emergent hemodialysis.
-Patient had episodes of vomiting and nausea.
Patient was not ordering any meals. Noted patient
had applesauce for lunch today. Patients
medication for malaria is making her nauseous.
PES:
Inadequate oral intake related to clinical condition
as evidenced by nausea/vomiting, intake < 50%
estimated energy requirements and poor appetite.
NUTRITION INTERVENTION:
Regular Diet + Ensure Compact BID with meals.
Will continue to monitor intake and weight
changes closely.
MONITOR/EVALUATE:Will continue to monitor
nutritional intake, diet tolerance, weight, labs and
stools during patients stay.
Progress: 6/10/19
-IV Artesunate was emergently delivered.
Parasitemia 2.4% → 0.8% → 0.1% → Negative.
-Patient received hemodialysis. Patient will require
dialysis for next few weeks (outpatient). GFR (7 ,
8).
-Patient placed on levophed, multiorgan sepsis is
improving and transaminases improving. Remains
anuric.
-Patient stabilized and able to be transferred out
from the ICU to the medical floor
-Patient on a regular diet. Patient ordered 2 meals
yesterday around 1000 kcal and 29 gm protein.
PES: Inadequate oral intake related to clinical
condition as evidenced by consuming < 75%
estimated energy needs
NUTRITION INTERVENTION: Continue
Regular Diet + Ensure compact BID with meals.
May wish to initiate nutrition support if PO
intakes are correct. . Request updated PO intake.
RD will attempt nutrition focused physical exam
per follow up visit.
MONITOR/EVALUATE:Will continue to monitor
nutritional intake, diet tolerance, weight, labs and
stools during patients stay.
 ● Patient only meeting 13% of her estimated energy needs and 6%
of her estimated protein needs.

● Estimated energy needs: 1863 kcal/day (Mifflin x 1.3 activity

factor (used admit weight)

Progress
Estimated protein needs: 81-88 gm/day (1.2-1.3 gm/kg admit
weight (dialysis)

● INTERVENTION: May wish to initiate nutrition support due to

6/11/19 poor P.O. intakes. TF recommendations: Nepro at 45 ml/hr over
22 hours + Prostat (daily). This would provide 1882 kcal, 97 gm
protein, 166 gm carbohydrate, and 720 ml free water over 22
hours to allow for patient care interruptions. MD discretion for
free water flushes.
Progress: 6/13/19
● Patient doesn't have much of an appetite.
Patient stated she is only able to get a couple
of bites of food. Patient vomits when she
eats. Patient has started eating with zofran.

● Patient did not need nutrition focused

physical exam.

● Patient is drinking Ensure Compact BID,

but feels nauseous.

● Patient may benefit from GI consult due to

vomiting with intake.
Final Encounter: 6/14/19
● Patient’s nausea with meals resolving,
MD holding Zofran to see cause of
nausea. Permcath placed due to anuric
state.
● Patient is feeling hungry today. Patient
ordered oatmeal for breakfast and
ordered a large lunch.
● Outpatient dialysis set up MWF upon
discharge.
PES: Inadequate oral intake related to clinical
condition as evidenced by consuming < 75%
estimated energy needs
NUTRITION INTERVENTION: Continue
Regular Diet + Ensure compact BID with meals.
RD will monitor diet tolerance and PO intake.
MONITOR / EVALUATE: Will continue to
monitor nutritional intake, diet tolerance, weight,
labs and stools during patients stay.
Intervention
- Regular Diet + Ensure compact BID with meals

- Nutrition support if poor PO intake continues.

- TF recommendations: Nepro at 45 ml/hr over 22 hours + Prostat (daily).
- This would provide 1882 kcal, 97 gm protein, 166 gm carbohydrate, and 720 ml free water over 22
hours to allow for patient care interruptions. for free water flushes.
Monitor and Evaluate
- Intake

- Diet tolerance

- Weight

- Labs

- Stools
Conclusion
Patient was here for a total of 14 days with severe malaria.

Hospital course
- By 6/8 Malaria smear was negative, however patient’s AKI and liver function worsening.
Central line was placed for hemodialysis and started on levophed for septic shock. Patient
was stabilized and transferred from ICU to medical floor. She had a permcath placed and
outpatient HD arranged. Her malarial smears remained negative. Patient thereafter was
medically stable for discharge.
Nutrition during course
- Patient never consumed more than 25% of meals ordered. Consumed < 50% of estimated
energy needs during stay.
Questions?
Thank you!
Citations
Global Health, Division of Parasitic Diseases and Malaria. (2019, January 4). CDC - Malaria - About Malaria - Disease. Retrieved June
11, 2019, from https://www.cdc.gov/malaria/about/disease.html

Mayo Clinic. (2018, December 13). Malaria. Retrieved from https://www.mayoclinic.org/diseases-conditions/malaria/symptoms-

causes/syc-20351184

World Health Organization. (2019, March 27). Fact sheet about Malaria. Retrieved from https://www.who.int/news-room/fact-
sheets/detail/malaria