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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="s0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025">Introduction</span><p id="p0005" class="elsevierStylePara elsevierViewall">Malaria is caused by the protozoa <span class="elsevierStyleItalic">Plasmodium</span>&#44; <a class="elsevierStyleCrossRef" href="#bb0005"><span class="elsevierStyleSup">1</span></a> with an intra and extra erythrocyte life cycle&#44; and man is infected by the bite of the anopheles mosquito&#46; There are four species responsible for human malaria&#58; <span class="elsevierStyleItalic">Plasmodium falciparum&#44; P&#46; vivax&#44; P&#46; ovale</span> and <span class="elsevierStyleItalic">P&#46; malariae&#46;</span></p><p id="p0010" class="elsevierStylePara elsevierViewall">Most cases of imported malaria are caused by <span class="elsevierStyleItalic">P&#46; falciparum&#46;</span> It is characterized by fever&#44; chills&#44; intense sweating and headaches&#44; that arise between the 9<span class="elsevierStyleSup">th</span> and 14<span class="elsevierStyleSup">th</span> days after bite&#46; Incubation can last for months&#46;</p><p id="p0015" class="elsevierStylePara elsevierViewall">With postponed diagnosis erythrocyte parasitemia may reach critical values&#44; massive hemolysis and multiorgan dysfunction resulting in death&#46;</p><p id="p0020" class="elsevierStylePara elsevierViewall">The pulmonary involvement with edema is a major complication&#46; <a class="elsevierStyleCrossRef" href="#bb0010"><span class="elsevierStyleSup">2</span></a> More common in adults&#44; is more severe in pregnant and non-immunized individuals&#46; <a class="elsevierStyleCrossRef" href="#bb0015"><span class="elsevierStyleSup">3</span></a> The alveolar-capillary barrier suffers increased permeability and alveolar flooding&#44; conditioning acute lung injury&#47;acute respiratory distress syndrome &#40;ARDS&#41;&#46; <a class="elsevierStyleCrossRef" href="#bb0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0030">Case report</span><p id="p0025" class="elsevierStylePara elsevierViewall">Man&#44; 44 year old&#44; black&#44; born in Angola and resident in Portugal for 24 years&#44; where he works in building construction&#46;</p><p id="p0030" class="elsevierStylePara elsevierViewall">Medical and surgical history irrelevant&#46; Denies alcohol or smoking habits&#44; illicit drug use or sexual risk contacts&#46; He had returned from Angola two weeks ago from his first trip there&#44; without taking any precaution&#46;</p><p id="p0035" class="elsevierStylePara elsevierViewall">He recurs to the emergency room with fever &#40;40<span class="elsevierStyleHsp" style=""></span>&#186;C&#41; and general malaise of a week duration&#44; and watery stools since the last three days&#46;</p><p id="p0040" class="elsevierStylePara elsevierViewall">He presented with a reasonable general condition&#44; dry mucous membranes and icteric sclerae&#46; A hypotensive and tachycardic profile was noted&#44; while being apyretic with good peripheral saturations on ambient air&#46;</p><p id="p0045" class="elsevierStylePara elsevierViewall">No obvious focus of infection was detected and the rest of the objective examination was irrelevant&#46;</p><p id="p0050" class="elsevierStylePara elsevierViewall">Initial laboratory parameters was as follow&#58; hemoglobin 11&#46;9<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; WBC 7&#44;200&#47;&#956;L&#44; platelets 27&#44;000&#47;&#956;L&#59; normal ionogram and renal function&#44; mild liver cytolysis without hyperbilirubinemia&#44; LDH 693 U&#47;L&#44; C-reactive protein &#40;CRP&#41; 228&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; Positive thick smear for <span class="elsevierStyleItalic">Plasmodium</span> with 43 &#37; of parasitemia &#40;<a class="elsevierStyleCrossRef" href="#f0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="f0005"></elsevierMultimedia><p id="p0055" class="elsevierStylePara elsevierViewall">Therapy was started with quinine sulfate and doxycycline&#46;</p><p id="p0060" class="elsevierStylePara elsevierViewall">Infection with hepatotropic virus&#44; HIV I&#47;II&#44; intestinal parasites&#44; urinary tract infection&#44; bacterial gastroenteritis or bacteraemia was excluded&#46; The chest radiograph shows no abnormality&#46;</p><p id="p0065" class="elsevierStylePara elsevierViewall">On the 3<span class="elsevierStyleSup">rd</span> hospital day &#40;D3&#41;&#44; the patient became more obtunded&#44; pale&#44; dehydrated&#44; and more icteric with profuse sweating&#44; fever&#44; tachypnea and hemodynamic instability&#46; On pulmonary auscultation there was new bilateral inspiratory crackles&#46;</p><p id="p0070" class="elsevierStylePara elsevierViewall">Hemoglobin fall to 6&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;dL accompanied by hyperbilirubinemia&#44; LDH &#61; 801 U&#47;L&#44; haptoglobin &#60; 7<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; thrombocytopenia &#40;37&#44;000&#47;&#956;L&#41;&#44; creatinine 1&#46;7<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and mild hyponatremia&#46; The CRP remained high and procalcitonin reached 42&#46;6<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; <span class="elsevierStyleItalic">Plasmodium</span> on direct examination was negative&#46; The characterization of the agent trough the BinaxNOW&#174; test showed a single antigen band for <span class="elsevierStyleItalic">P&#46; falciparum&#46;</span></p><p id="p0075" class="elsevierStylePara elsevierViewall">The patient was admitted to a High-Dependency Unit &#40;HDU&#41;&#44; with multiple dysfunctions&#44; including cardiovascular&#44; hematological&#44; renal&#44; hepatic and respiratory systems &#40;PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> &#61; 129&#41; with criteria for ARDS &#40;<a class="elsevierStyleCrossRef" href="#f0010">Fig&#46; 2</a>&#41;&#46; After attempts was made to exclude secondary septic complications&#44; to the general support measures&#44; which included liberal fluids infusion and transfusion of packed red blood cells&#44; an empiric antimicrobial coverage with linezolid plus piperacillin&#47;tazobactam was instituted&#46;</p><elsevierMultimedia ident="f0010"></elsevierMultimedia><p id="p0080" class="elsevierStylePara elsevierViewall">By D7 the clinical situation allowed us to continue treatment in the general ward&#46; On D8&#44; a clear improvement on radiological findings and gas exchange was noted&#46; The microbiological screening remained negative&#44; and so&#44; we proceed therapy with only quinine sulfate&#46;</p><p id="p0085" class="elsevierStylePara elsevierViewall">By D11 hemoglobin was 9&#46;2<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; with no leukocytosis or thrombocytopenia&#44; and renal function&#44; bilirubin and CRP normalized or continued to improve&#46; <span class="elsevierStyleItalic">Plasmodium</span> on ticks mear remained negative&#46; Abdominal ultrasound excluded pathologic findings&#46;</p><p id="p0090" class="elsevierStylePara elsevierViewall">The patient lived the hospital with a good general condition&#44; with permanent apyrexia and without need for oxygen supply&#46; On a subsequent ambulatory revision&#44; a completely normal clinical status was verified&#46;</p></span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0035">Discussion and conclusions</span><p id="p0095" class="elsevierStylePara elsevierViewall">Malaria presentation is very unspecific so alternative and more frequent diagnoses should be excluded&#44; such as severe pneumonia&#44; meningitis&#44; hemorrhagic fevers&#44; salmonellosis&#44; viral hepatitis and dengue&#46; Fever is common and should be treated with paracetamol&#44; to minimize bleeding diathesis&#46; It responds poorly to antipyretics and physical measures can be necessary&#46;</p><p id="p0100" class="elsevierStylePara elsevierViewall">Imported malaria&#44; in the beginning rarely follows the classical pattern of tertian or quartan fever&#44; which appears only after a few cycles when synchronization occurs&#46; Additional symptoms include chills&#44; headache&#44; malaise&#44; nausea&#44; vomiting&#44; diarrhea&#44; abdominal pain and myalgia&#46; Splenomegaly is an inconstant finding&#46; In practice&#44; malaria should be suspected in any febrile individual returning from tropics&#44; especially if coexisting anemia&#44; thrombocytopenia or cytolysis&#46;</p><p id="p0105" class="elsevierStylePara elsevierViewall">10 &#37; of all cases have a malignant evolution&#46; 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200<span class="elsevierStyleHsp" style=""></span>mmHg&#46;</p><p id="p0130" class="elsevierStylePara elsevierViewall">The absence jugular engorgement&#44; hepatojugular reflux&#44; peripheral edema and the typical &#8220;butterfly&#8221; infiltrates and cephalic pulmonary blood redistribution on chest x-ray&#44; don&#39;t support cardiogenic edema&#46; These parameters helped us to guide the fluids supplementation&#44; without jeopardize gas exchange&#46; However&#44; alveolar-capillary damage really favors pulmonary edema formation&#46;</p><p id="p0135" class="elsevierStylePara elsevierViewall">Non-cardiogenic pulmonary edema rarely occurs with other species then <span class="elsevierStyleItalic">P&#46; falciparum&#46;</span></p><p id="p0140" class="elsevierStylePara elsevierViewall">Quinine sulfate is the drug of choice for severe mal&#225;ria&#44; but caution should be taken in those patients with a family history of sudden death or long QT by its intrinsic arrhythmogenicity&#46; Glocunato form is even more pro-arrhythmic&#46;</p><p id="p0145" class="elsevierStylePara elsevierViewall">Severe and recurrent hypoglycemia can result from hyperinsulinism induced by quinine&#47;quinidine&#44; malarious toxins or massive parasitism&#46;</p><p id="p0150" class="elsevierStylePara elsevierViewall">Renal failure&#44; usually oliguric&#44; rarely requires dialysis support and reverses in days&#46;</p><p id="p0155" class="elsevierStylePara elsevierViewall">Thrombocytopenia is common&#44; but rarely contributes to hemorrhagic diathesis&#46; Anemia is induced by parasitic hemolysis&#46;</p><p id="p0160" class="elsevierStylePara elsevierViewall">The fever increases during the first two days but should disappear after 48 hours of treatment&#46;</p><p id="p0165" class="elsevierStylePara elsevierViewall">The efficacy of treatment must be verified by microscopic examination of the blade&#46; The degree of parasitaemia decreases 90 &#37; in 48 hours and must be zero at D3&#46;</p><p id="p0170" class="elsevierStylePara elsevierViewall">The actual case illustrates the counsequencies of preventive measures failure&#44; such as chemoprophylaxis&#46;</p><p id="p0175" class="elsevierStylePara elsevierViewall">If a parasitaemia score of 5 &#37; 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CASE REPORT
Severe malaria – Clinical case
Malária grave – Caso clínico
A. Piresa,
Corresponding author
arnpires@gmail.com

Corresponding author.
, C. Capelaa, P. Gouveiaa, J.A. Mariza, G. Gomesb, J.E. Oliveirab
a Internal Medicine Department, Hospital de Braga, Braga, Portugal
b Internal Medicine, Intensive Care Unit, Hospital de Braga, Braga, Portugal
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          "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">Picture of the patient&#39;s peripheral blood smear showing a very high level of parasitemia with images of trophozoites and merozoites&#44; as well as significant schizocytes&#46; There were no gametocytes and therefore cannot be seen here&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="s0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025">Introduction</span><p id="p0005" class="elsevierStylePara elsevierViewall">Malaria is caused by the protozoa <span class="elsevierStyleItalic">Plasmodium</span>&#44; <a class="elsevierStyleCrossRef" href="#bb0005"><span class="elsevierStyleSup">1</span></a> with an intra and extra erythrocyte life cycle&#44; and man is infected by the bite of the anopheles mosquito&#46; There are four species responsible for human malaria&#58; <span class="elsevierStyleItalic">Plasmodium falciparum&#44; P&#46; vivax&#44; P&#46; ovale</span> and <span class="elsevierStyleItalic">P&#46; malariae&#46;</span></p><p id="p0010" class="elsevierStylePara elsevierViewall">Most cases of imported malaria are caused by <span class="elsevierStyleItalic">P&#46; falciparum&#46;</span> It is characterized by fever&#44; chills&#44; intense sweating and headaches&#44; that arise between the 9<span class="elsevierStyleSup">th</span> and 14<span class="elsevierStyleSup">th</span> days after bite&#46; Incubation can last for months&#46;</p><p id="p0015" class="elsevierStylePara elsevierViewall">With postponed diagnosis erythrocyte parasitemia may reach critical values&#44; massive hemolysis and multiorgan dysfunction resulting in death&#46;</p><p id="p0020" class="elsevierStylePara elsevierViewall">The pulmonary involvement with edema is a major complication&#46; <a class="elsevierStyleCrossRef" href="#bb0010"><span class="elsevierStyleSup">2</span></a> More common in adults&#44; is more severe in pregnant and non-immunized individuals&#46; <a class="elsevierStyleCrossRef" href="#bb0015"><span class="elsevierStyleSup">3</span></a> The alveolar-capillary barrier suffers increased permeability and alveolar flooding&#44; conditioning acute lung injury&#47;acute respiratory distress syndrome &#40;ARDS&#41;&#46; <a class="elsevierStyleCrossRef" href="#bb0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0030">Case report</span><p id="p0025" class="elsevierStylePara elsevierViewall">Man&#44; 44 year old&#44; black&#44; born in Angola and resident in Portugal for 24 years&#44; where he works in building construction&#46;</p><p id="p0030" class="elsevierStylePara elsevierViewall">Medical and surgical history irrelevant&#46; Denies alcohol or smoking habits&#44; illicit drug use or sexual risk contacts&#46; He had returned from Angola two weeks ago from his first trip there&#44; without taking any precaution&#46;</p><p id="p0035" class="elsevierStylePara elsevierViewall">He recurs to the emergency room with fever &#40;40<span class="elsevierStyleHsp" style=""></span>&#186;C&#41; and general malaise of a week duration&#44; and watery stools since the last three days&#46;</p><p id="p0040" class="elsevierStylePara elsevierViewall">He presented with a reasonable general condition&#44; dry mucous membranes and icteric sclerae&#46; A hypotensive and tachycardic profile was noted&#44; while being apyretic with good peripheral saturations on ambient air&#46;</p><p id="p0045" class="elsevierStylePara elsevierViewall">No obvious focus of infection was detected and the rest of the objective examination was irrelevant&#46;</p><p id="p0050" class="elsevierStylePara elsevierViewall">Initial laboratory parameters was as follow&#58; hemoglobin 11&#46;9<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; WBC 7&#44;200&#47;&#956;L&#44; platelets 27&#44;000&#47;&#956;L&#59; normal ionogram and renal function&#44; mild liver cytolysis without hyperbilirubinemia&#44; LDH 693 U&#47;L&#44; C-reactive protein &#40;CRP&#41; 228&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; Positive thick smear for <span class="elsevierStyleItalic">Plasmodium</span> with 43 &#37; of parasitemia &#40;<a class="elsevierStyleCrossRef" href="#f0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="f0005"></elsevierMultimedia><p id="p0055" class="elsevierStylePara elsevierViewall">Therapy was started with quinine sulfate and doxycycline&#46;</p><p id="p0060" class="elsevierStylePara elsevierViewall">Infection with hepatotropic virus&#44; HIV I&#47;II&#44; intestinal parasites&#44; urinary tract infection&#44; bacterial gastroenteritis or bacteraemia was excluded&#46; The chest radiograph shows no abnormality&#46;</p><p id="p0065" class="elsevierStylePara elsevierViewall">On the 3<span class="elsevierStyleSup">rd</span> hospital day &#40;D3&#41;&#44; the patient became more obtunded&#44; pale&#44; dehydrated&#44; and more icteric with profuse sweating&#44; fever&#44; tachypnea and hemodynamic instability&#46; On pulmonary auscultation there was new bilateral inspiratory crackles&#46;</p><p id="p0070" class="elsevierStylePara elsevierViewall">Hemoglobin fall to 6&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;dL accompanied by hyperbilirubinemia&#44; LDH &#61; 801 U&#47;L&#44; haptoglobin &#60; 7<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; thrombocytopenia &#40;37&#44;000&#47;&#956;L&#41;&#44; creatinine 1&#46;7<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and mild hyponatremia&#46; The CRP remained high and procalcitonin reached 42&#46;6<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; <span class="elsevierStyleItalic">Plasmodium</span> on direct examination was negative&#46; The characterization of the agent trough the BinaxNOW&#174; test showed a single antigen band for <span class="elsevierStyleItalic">P&#46; falciparum&#46;</span></p><p id="p0075" class="elsevierStylePara elsevierViewall">The patient was admitted to a High-Dependency Unit &#40;HDU&#41;&#44; with multiple dysfunctions&#44; including cardiovascular&#44; hematological&#44; renal&#44; hepatic and respiratory systems &#40;PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> &#61; 129&#41; with criteria for ARDS &#40;<a class="elsevierStyleCrossRef" href="#f0010">Fig&#46; 2</a>&#41;&#46; After attempts was made to exclude secondary septic complications&#44; to the general support measures&#44; which included liberal fluids infusion and transfusion of packed red blood cells&#44; an empiric antimicrobial coverage with linezolid plus piperacillin&#47;tazobactam was instituted&#46;</p><elsevierMultimedia ident="f0010"></elsevierMultimedia><p id="p0080" class="elsevierStylePara elsevierViewall">By D7 the clinical situation allowed us to continue treatment in the general ward&#46; On D8&#44; a clear improvement on radiological findings and gas exchange was noted&#46; The microbiological screening remained negative&#44; and so&#44; we proceed therapy with only quinine sulfate&#46;</p><p id="p0085" class="elsevierStylePara elsevierViewall">By D11 hemoglobin was 9&#46;2<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; with no leukocytosis or thrombocytopenia&#44; and renal function&#44; bilirubin and CRP normalized or continued to improve&#46; <span class="elsevierStyleItalic">Plasmodium</span> on ticks mear remained negative&#46; Abdominal ultrasound excluded pathologic findings&#46;</p><p id="p0090" class="elsevierStylePara elsevierViewall">The patient lived the hospital with a good general condition&#44; with permanent apyrexia and without need for oxygen supply&#46; On a subsequent ambulatory revision&#44; a completely normal clinical status was verified&#46;</p></span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0035">Discussion and conclusions</span><p id="p0095" class="elsevierStylePara elsevierViewall">Malaria presentation is very unspecific so alternative and more frequent diagnoses should be excluded&#44; such as severe pneumonia&#44; meningitis&#44; hemorrhagic fevers&#44; salmonellosis&#44; viral hepatitis and dengue&#46; Fever is common and should be treated with paracetamol&#44; to minimize bleeding diathesis&#46; It responds poorly to antipyretics and physical measures can be necessary&#46;</p><p id="p0100" class="elsevierStylePara elsevierViewall">Imported malaria&#44; in the beginning rarely follows the classical pattern of tertian or quartan fever&#44; which appears only after a few cycles when synchronization occurs&#46; Additional symptoms include chills&#44; headache&#44; malaise&#44; nausea&#44; vomiting&#44; diarrhea&#44; abdominal pain and myalgia&#46; Splenomegaly is an inconstant finding&#46; In practice&#44; malaria should be suspected in any febrile individual returning from tropics&#44; especially if coexisting anemia&#44; thrombocytopenia or cytolysis&#46;</p><p id="p0105" class="elsevierStylePara elsevierViewall">10 &#37; of all cases have a malignant evolution&#46; These are mostly induced by <span class="elsevierStyleItalic">P&#46; falciparum</span> and may follow a explosive course with 50 &#37; of deaths occurring in the first 24 hours&#46; <a class="elsevierStyleCrossRef" href="#bb0025"><span class="elsevierStyleSup">5</span></a></p><p id="p0110" class="elsevierStylePara elsevierViewall">Diagnosis is made by direct demonstration of parasites in blood&#46; Parasitaemia should be determined initially&#44; at D3&#44; D7 and D28&#44; to assess severity&#44; therapy monitoring and late failures detection&#46; <a class="elsevierStyleCrossRef" href="#bb0030"><span class="elsevierStyleSup">6</span></a></p><p id="p0115" class="elsevierStylePara elsevierViewall">Agent detection can imply repeating tests at 12<span class="elsevierStyleHsp" style=""></span>h intervals&#44; but is generally accepted treating patients empirically if suspicion remains high&#46;</p><p id="p0120" class="elsevierStylePara elsevierViewall">Malaria is a paradigmatic example where the early therapy and intensive monitoring brings benefits&#46;</p><p id="p0125" class="elsevierStylePara elsevierViewall">ARDS is defined by acute onset of bilateral pulmonary infiltrates in the absence of heart failure and a PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> &#8804; 200<span class="elsevierStyleHsp" style=""></span>mmHg&#46;</p><p id="p0130" class="elsevierStylePara elsevierViewall">The absence jugular engorgement&#44; hepatojugular reflux&#44; peripheral edema and the typical &#8220;butterfly&#8221; infiltrates and cephalic pulmonary blood redistribution on chest x-ray&#44; don&#39;t support cardiogenic edema&#46; These parameters helped us to guide the fluids supplementation&#44; without jeopardize gas exchange&#46; However&#44; alveolar-capillary damage really favors pulmonary edema formation&#46;</p><p id="p0135" class="elsevierStylePara elsevierViewall">Non-cardiogenic pulmonary edema rarely occurs with other species then <span class="elsevierStyleItalic">P&#46; falciparum&#46;</span></p><p id="p0140" class="elsevierStylePara elsevierViewall">Quinine sulfate is the drug of choice for severe mal&#225;ria&#44; but caution should be taken in those patients with a family history of sudden death or long QT by its intrinsic arrhythmogenicity&#46; Glocunato form is even more pro-arrhythmic&#46;</p><p id="p0145" class="elsevierStylePara elsevierViewall">Severe and recurrent hypoglycemia can result from hyperinsulinism induced by quinine&#47;quinidine&#44; malarious toxins or massive parasitism&#46;</p><p id="p0150" class="elsevierStylePara elsevierViewall">Renal failure&#44; usually oliguric&#44; rarely requires dialysis support and reverses in days&#46;</p><p id="p0155" class="elsevierStylePara elsevierViewall">Thrombocytopenia is common&#44; but rarely contributes to hemorrhagic diathesis&#46; Anemia is induced by parasitic hemolysis&#46;</p><p id="p0160" class="elsevierStylePara elsevierViewall">The fever increases during the first two days but should disappear after 48 hours of treatment&#46;</p><p id="p0165" class="elsevierStylePara elsevierViewall">The efficacy of treatment must be verified by microscopic examination of the blade&#46; The degree of parasitaemia decreases 90 &#37; in 48 hours and must be zero at D3&#46;</p><p id="p0170" class="elsevierStylePara elsevierViewall">The actual case illustrates the counsequencies of preventive measures failure&#44; such as chemoprophylaxis&#46;</p><p id="p0175" class="elsevierStylePara elsevierViewall">If a parasitaemia score of 5 &#37; reflects severity&#44; the 43 &#37; presented by out promised a complicated evolution&#44; as was the case with the installation of successive failures that culminated in ARDS&#46;</p><p id="p0180" class="elsevierStylePara elsevierViewall">The inability to microscopically characterize the type of <span class="elsevierStyleItalic">Plasmodium&#44;</span> do limited therapy institution&#46; Results of the BinaxNOW&#174; test&#44; showing a single band for <span class="elsevierStyleItalic">P&#46; falciparum</span> antigen&#44; comes later&#46; Genomic identification by polymerase chain reaction &#40;PCR&#41; is another available mean to identify the <span class="elsevierStyleItalic">Plasmodium&#46;</span></p><p id="p0185" class="elsevierStylePara elsevierViewall">Compared with PCR&#44; BinaxNOW&#174; test showed a sensitivity of 94 &#37; for detection of P <span class="elsevierStyleItalic">falciparum</span> and 84 &#37; for other species&#44; with overall specificity of 99 &#37;&#46;&#40;7&#44;8&#41;</p><p id="p0190" class="elsevierStylePara elsevierViewall">Multiorgan dysfunction&#44; led us to admit secondary sepsis superposed on malaria&#44; influencing the strategy&#46;</p><p id="p0195" class="elsevierStylePara elsevierViewall">Despite severity of the condition and the limited clinical experience&#44; admission to a HDU capable of monitoring and early warning to complications&#44; associated with elected conduct&#44; proved critical to reverse the various dysfunctions&#44; allowing the avoidance of mechanical ventilation&#46;</p><p id="p0200" class="elsevierStylePara elsevierViewall">Although relatively rare in Portugal&#44; the clinical picture of malaria tends to change with progressive flow of people between countries with multiple affinities&#44; as is the case of Portugal with African ex-colonies&#46;</p></span></span>"
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        "resumen" => "<p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">We report a clinical case of severe malaria&#44; where the rate of initial parasitaemia by <span class="elsevierStyleItalic">Plasmodium falciparum</span> was 43 &#37;&#46;</p><p id="sp0020" class="elsevierStyleSimplePara elsevierViewall">Multiple organ dysfunction&#44; including ARDS&#44; forced admission in a close surveillance unit&#44; with survival of the same&#46;</p><p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">A brief review of the subject is made&#44; focusing on severity and general conduct&#44; alerting and awareness for this entity&#44; whose expression&#44; among us&#44; could take on increasing importance&#46;</p>"
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        "resumen" => "<p id="sp0030" class="elsevierStyleSimplePara elsevierViewall">Apresenta-se o caso cl&#237;nico de um doente regressado de Angola com mal&#225;ria grave&#44; em que o &#237;ndice de parasit&#233;mia inicial pelo <span class="elsevierStyleItalic">P&#46; falciparum</span> era de 43 &#37;&#46;</p><p id="sp0035" class="elsevierStyleSimplePara elsevierViewall">Disfun&#231;&#227;o m&#250;ltipla de org&#227;os&#44; incluindo ARDS&#44; implicaram o ingresso do doente numa unidade de alta vigil&#226;ncia&#44; com sobreviv&#234;ncia do mesmo&#46;</p><p id="sp0040" class="elsevierStyleSimplePara elsevierViewall">Faz-se uma breve revis&#227;o do assunto&#44; com enfoque nos indicadores de gravidade e na conduta geral&#44; alertando e sensibilizando para esta entidade&#44; cuja express&#227;o&#44; entre n&#243;s&#44; poder&#225; vir a assumir import&#226;ncia crescente&#46;</p>"
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ISSN: 21735115
Original language: English
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Pulmonology

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