ChloroquineV1, Istex, Corpus, bibRecord, 000D00

Transfusion Malaria

Identifieur interne : 000D00 ( Istex/Corpus ); précédent : 000C99; suivant : 000D01

Transfusion Malaria

Auteurs : S. N. Pantelakis ; A. Karaklis ; S. A. Doxiadis

Source :

Clinical Pediatrics [ 0009-9228 ] ; 1966-09.

RBID : ISTEX:2A94944C4721C50F75700D3C9451FF169D06D74A

English descriptors

Teeft :
- Aghia sophia, Antimalarial treatment, Birth weight, Blood examination, Blood films, Blood smears, Blood transfusion, Blood transfusions, Clinic, Congenital transmission, Costal, Costal margin, Department april, Excellent condition, Family doctor, Female infant, General condition, High fever, Incubation periods, Initial dose, Jaundice, Malaria, Malariae, Male infant, Many years, Maternity clinic, Mature trophozoites, Normal delivery, Other hand, Palpable, Pediatric clinic, Plasmodia malariae, Plasmodium, Plasmodium malariae, Pulse rate, Quartan malaria, Same clinic, Schizonts, Small blood transfusions, Spleen, Transfusion, Transfusion malaria, Trophozoite, Young patients.

Url:

https://api.istex.fr/ark:/67375/M70-C6CX6V81-Z/fulltext.pdf

DOI: 10.1177/000992286600500909

Links to Exploration step

ISTEX:2A94944C4721C50F75700D3C9451FF169D06D74A

Le document en format XML

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<meta-value>543 Infectious DiseasesTransfusion MalariaSeven Affected Infants SAGE Publications, Inc.1966DOI: 10.1177/000992286600500909 S.N. Pantelakis Children's Hospital "Aghia Sophia," Athens, Greece A. Karaklis Blood Bank and Hematology Laboratory of Children's Hospital "Aghia Sophia" S.A. Doxiadis Pediatric Unit, Children's Hospital "Aghia Sophia" UNTIL the year 1945, Greece had the highest malaria endemicity of any country of Europe. The systematic spraying with chlorinated hydrocarbon insecticides, which began in 1946, soon resulted in the almost complete eradication of the disease, so that today very few autochthonous cases of malaria are reported:> 9 . We were therefore surprised to discover seven new cases of quartan malaria among the infants admitted between January and October 1963 to the Pediatric Clinic of the Children's Hospital "Aghia Sophia" in Athens. Plasmodium malariae was identified as the causative agent in each of these cases within a few hours after admission, by detection of the parasites in smears of peripheral blood. Every one of these young patients had this in common-each had been the recipient of one or more small blood transfusions at a private pediatric clinic in Athens. Treatment was started as soon as the diagnostic and other tests were completed. Treatment consisted of two drugs; chloroquine for three days (8 mg. per Kg. as the initial dose, half the initial dose six hours later "and repeated after 24 hours and 48 hours) andPriznaquine (4 ray, daily for 15 days);'after ruling out G-6-PD deficiency. Description of Cases Case .~. This infant girl was born in a maternity clinic in Athens August 17, 1962, with normal delivery. Birth weight was 1,450 Gm. Because of prematurity the infant was transferred to a private pediatric clinic where she was nursed for three months. During this period she was given small blood transfusions as part of the supportive therapy for prematures used at that clinic. Following discharge from there she did not gain weight satisfactorily. At five months of age she was extremely pale and anorexic. The family doctor diagnosed iron deficiency anemia and gave intramuscular injections of iron. Ten days later she was still pale and had a cough. For these reasons she was admitted to our department January 30, 1963, at the age of five and one-half months. On admission the infant appeared very pale, and had tachycardia (pulse rate 210 per min.). Disseminated rhonchi were noted in both lungs, the liver was palpable 4 cm. below the costal margin and the spleen, 3 cm. The Hb level was 5.8 Gm. per 100 ml. and the hematocrit 16.5 per cent. The blood smear revealed Plasmodium malariae (mature trophozoites, schizonts). A transfusion of 150 ml. of blood was given. Antimalarial treatment was begun. Seven days later the fever subsided, and subsequent blood examinations were negative for parasites. The child was discharged February 21. One month later her general condition was excellent. The liver was palpable 3 cm. below the costal margin and the spleen was just palpable. Blood examination was negative for plasmodia. Case 2. This female infant was born in a maternity hospital in Athens December 4, 1962, with normal delivery and birth weight of 2,200 Gm. Because of prematurity the infant was referred next day to the private pediatric clinic where she was nursed for 40 days. During this period she 24544 received two small blood transfusions. Following discharge she was well till the age of three months when high fever (39' C.), anorexia and restlessness began. The family doctor diagnosed sore throat and prescribed oral penicillin. Ten days later the fever persisted and jaundice had developed. For these reasons the infant was referred to our department April 5, 1963, at four months of age. On admission the infant was jaundiced, the liver was 2 cm. below the costal margin and the spleen, 3 cm. Blood Hb level was 5.8 Gm. per 100 ml., hematocrit 18 per cent. Plasmodia malariae were found in blood smears (young and mature trophozoites, schizonts, gametes). Antimalarial treatment was started two days following admission, and six days later the fever subsided. The child was discharged in excellent condition; however, follow up was not possible. Case 3. This male infant was born in a private maternity clinic November 29, 1962, with normal delivery and birth weight of 2,500 Gm. He was nursed for two months in the same private pediatric clinic because of prematurity. During this period two small blood transfusions were given. Following discharge he was well till age three and one-half months when he had high temperature and restlessness. The family doctor diagnosed influenza and prescribed a broad spectrum antibiotic. The infant was admitted to our department April 10, 1963, at the age of four and one-half months with pallor and persistent fever. The liver was palpable 4 cm. below the costal margin, and the spleen, 3 cm. Blood examination showed Hb 7.0 Gm., hematocrit 20 per cent, and Plasmodia malariae (mature trophozoites, schizonts, gametes). The parents insisted on taking the child home. Antimalarial treatment was given at home, but no further information is available. Case 4. This female infant was born in a maternity clinic in Athens May 1, 1963, with breech delivery and birth weight of 2,050 Gm. Because of prematurity she was referred to the private pediatric clinic where she remained for one month. During this period one small blood transfusion was given. Ten days after discharge she had febrile periods on alternate days. Since the fever persisted, she was re-admitted to the same clinic where the Hb level was found to be 5.3 Gm., and a blood transfusion of 50 ml. of blood was given. Following this hematuria and jaundices developed, and the infant was referred to -your department July 3. On admission she was jaun- diced. The liver was not palpable but the spleen was felt 3 cm. below the costal margin. Hb was 4.9 Gm. Plasmodia malariae were present in blood smears (young trophozoites, schizonts, gametes). Treatment was started and the temperature became normal by July 9 when she was discharged. Treatment was completed at home. , On a follow up examination a few days later the child was well and afebrile. The spleen was still palpable 3 cm. below the costal margin and the Hb level was 8.1 Gm. Examination of blood smears showed no plasmodia. ' Case 5. This male infant was born in a private maternity clinic in Athens April 29, 1963, with normal delivery and birth weight of 2,230 Gm. Because of prematurity he was referred to the private pediatric clinic where he stayed for one and one-half months. During this period he received three small blood transfusions. One month after discharge he became anorexic and fever developed. Four days later, after the fever persisted, the family doctor prescribed a broad spectrum antibiotic, which was without benefit. The infant was referred to our Unit July 23, at the age of two months and three weeks. On admission he was pale, and the liver palpable 3 cm. below the costal margin and the spleen, 2 cm. His Hb level was 4.9 Gm. per 100 ml. His blood smears contained Plasmodia malariae (mature trophozoites, schizonts, gametes). Few hours following admission the baby developed dyspnea, cyanosis and became more pale. The Hb level was 4 Gm. We immediately gave him oxygen, a blood transfusion of 50 ml. of packed red cells, and started specific treatment. His condition improved rapidly. The hemoglobin level following transfusion was 8.9 Gm. Two days later there was another attack of dyspnea and cyanosis and a decrease in Hb to 6.2 Gm. A chest x-ray showed bronchopneumonia. Penicillin treatment was started and a new blood transfusion of 100 ml. given. Edema of the eyelids and lower limbs followed, and the urine showed albumin, a few white cells, and many red cells and granular casts. His general condition remained poor and he died August 2 at the age of three months and three days. Case 6. This male infant was born in a maternity clinic of Lamia March 3, 1963, with normal delivery and birth weight of 1,900 Gm. He was nursed in that clinic for 15 days and was discharged in good condition. Ten days later the infant developed a temperature of 40° C. The family doctor diagnosed bronchopneumonia and referred the baby to the already mentioned private pediatric clinic in Athens. The infant stayed in that clinic for two months and was given a blood transfusion for anemia. He was discharged June 3, at the age of three months. Fifteen days later he developed fever again, followed four days later by jaundice with bile-stained urine. He was re-admitted to the same clinic where obstructive jaundice was diagnosed, and an exploratory laparotomy recommended. The parents refused the operation and brought their child to our department. 25545 He was admitted here July 24, at the age of four and one-half months. Physical examination revealed jaundice and pallor; the liver was palpable 3 cm. below the costal margin and the spleen was not palpable. A blood examination showed Hb 6.8 Gm. and the presence of Plasmodia malariae (mature trophozoites, schizonts, gametes). The total serum bilirubin was 8.6 mg./ 100 ml.; conjugated bilirubin, 6.0 mg./100 ml. Antimalarial treatment was started immediately. Vitamin K was also given. The temperature was normal the following day and jaundice subsided gradually. Fifteen days later a repeat blood examination showed no plasmodia. He was discharged August 11 in excellent condition with no jaundice. On a follow up examination three weeks later there were no abnormal clinical or laboratory findings. Case 7. This male infant, born in a private maternity clinic cxf Athens with normal delivery and birth weight 1,960 Gm., was referred and nursed for two months in the private pediatric clinic of Athens because of prematurity. During this period he received three small blood transfusions. Twenty days after discharge he was re-admitted to the same clinic because in a follow up examination there were fine rales in both lungs. One week after admission he began to have high fever, and had six episodes of convulsions. He was discharged September 9, 50 days after his second admission. Because febrile episodes persisted he was examined by another doctor who suspected malaria and sent the child to our department for investigation. On admission here October 7, the infant was pale and dyspneic. Pulse rate 165, liver and spleen palpable 3 cm. below the respective costal margins. A blood examination showed hemoglobin 7.8 Gm. and Plasmodia malariae (young and mature trophozoites, schizonts, gametes). Two days following initiation of antimalarial treatment his general condition improved and he became apy- rexic. He was discharged a week later and treat. ment was completed at home. Discussion The fact that within a period of. only ten months, seven young infants with malaria were encountered in one hospital unit appears at first quite surprising. - in countries with high malaria endemicity, congenital transmission through the placenta has been described, but this remains exceptional. For mothers having clinical attacks during their~ pregnancy, the frequency of congenital transmission has been calculated -as approximately I per cent.3 Not one of the mothers of our infants had had clinical symptoms of malaria during pregnancy or earlier. Furthermore, careful examinations of their blood had not shown the presence of plasmodia. Six of the seven cases described were from Athens, where malaria transmitted by mosquitoes has not been reported for many years. It was therefore thought improbable that such transmission might have occurred in our young patients. On the other hand, in every instance the disease became manifest after one or more small "tonic" blood transfusions given in one pediatric clinic. It seemed very likely, therefore, that we were dealing here with instances of transfusion malaria. The absolute proof of this hypothesis would be to detect in the blood donor, or donors, a Plasmodium of the same type as that found in the affected infants. In fact, finally, it became possible to discover, that one single donor had provided tlxe blood for every one of these infants! In that clinic the practice is to transfuse, for "supportive" therapy, several premature babies from a single donation of blood. Since elimination of the infected donor no further cases of malaria have developed among infants in that clinic. Regrettably, we can obtain no information regarding the visual identification of PlaswodtM~ malariae in this donor. Woolsey I° in 1911 was the first to draw attention to the danger of transmitting malaria by transfusion of fresh blood. Gordon 4 in 1941 emphasized the possibility of transmission of malaria from stored blood. A fair number of cases of transfusion malaria have been described in the literature. In most of the reported cases the donor was a healthy carrier of Plasmodium maylariae. This form of plasmodium can remain for several years in the reticuloendothelial system, mainly of the liver, in an inactive state (exoerythrocytic forms). From time to time and for many years after the initial infection some merozoites produced from this system may enter the circulation and again infect red cells.6 Transfusion malaria referable to Pl. vivax and Pl. falciparum has been reported less frequently. 26546 Malaria parasites can survive in the temperatures of the usual refrigerator. Hutton and Shute 7 state that all types of plasmodia can be kept alive for days or even weeks in the temperature of 4° C. On the other hand, Morcos,8 who studied the survival of Pl. vivax and Pl. malariae, has shown their survival to be not longer than 12 days. Malaria in infants of this age is quite unusual. In endemic areas malaria is exceptional in infants below six months of age and rare below the age of three months,6 because of passive immunity transmitted through the placenta. With the eradication of malaria from Greece, mothers no longer have acquired immunity and this may explain the early involvement of our patients. It was not possible to calculate with accuracy the incubation periods in our patients since we could not be sure of the exact dates of the transfusion or transfusions. At any rate the incubation periods were at least 30 days or longer. Prolonged incubation with malaria transmitted by blood transfusions has been reported by others.6 6 In six of our seven infants the symptoms were those typical of n~alaria-fe~er, splenomegaly, anemia. Nevertheless, the fact that only one of the infants was referred to the hospital with the clinical suspicion of malaria illustrates how rarely doctors consider this diagnosis today, and particularly with patients of such a young age. The severe hepatitis in two of our seven patients, and the death of another, are in accord with other reports regarding the somewhat unfavorable prognosis of malaria in very young infants.6 Early diagnosis and treatment are therefore of importance. It is unfortunate that blood transfusions were given to these patients when they were not necessary. Blood transfusions should not serve as a "tonic" in the absence of anemia. In countries where the eradication of ma- ° laria is still recent, the danger of transmission of the disease by blood transfusion is real and serious. In Sardinia, for instance, 21 of 44 reported cases of quartan malaria were transmitted by blood transfusions .2 The prevention of transfusion malaria from healthy carriers poses a serious problem to blood banks. As pointed out, these parasites are not destroyed by storing blood at 4° C. for a few days, and elimination of such donors by examination of blood films is practically impossible. In the case of transfusion malaria reported by Grant et al.,5 for example, careful examination of blood films by two experts for three hours failed to reveal the presence of parasites. However, a repeat examination ten days later detected a small number of parasites. There would seem to be only two practical methods for prevention of transfusion malaria : (a) To store fresh blood for at least 12 days in the refrigerator (4° C.) 8 before using. This has the great disadvantage that after such prolonged period of storage the survival time of red cells in the patient is appreciably shortened and the desired therapeutic benefit proportionately curtailed. (b) To give one dose of chloroquine either to the donor or to the recipient. Prophylaxis with chloroquine is thought to be more effective with recipients than with donors. References Belios, G.D. : Recent course and care pattern of malaria in relation to its control in Greece. Riv. Malar. 34: 1, 1955. Carrescia, P.M. : Malaria da transfusione, possibilita di profilassi . Riv. Malar. 39: 209, 1960. Faust, E.C. and Russel, P.F.: Clinical Parasitology. Philadelphia, Lea & Febiger, 1958, p. 281. Gordon, E.F. : Accidental transmission of malaria through administration of stored blood. J.A.M.A. 116: 1200, 1941 . Grant, D.B., Peripanayagam, M.S., Shute, P.G. and Zetlin, R.A.: A case of malignant tertian (Plasmodium falciparum) malaria after blood transfusion . Lancet ii: 469, 1960. Grislain, J. , DeFerron, A., Martouzet, B., Delaroche, E., LeDanois, A. and Mainard, R.: Paludisme du nourrisson. Ann. Paediat. 39: 31, 1963. Hutton, E.L. and Shute, P.G.: The risk of transmitting malaria by blood transfusion. J. Trop. Med. Hyg. 42: 309, 1939. Morcos, W.M. : Observations morphologiques des divers stades de plasmodiun vivax et de plasmodium malariae dans le sang conservé à froid pour transfusion. Riv. Malar. 40: 41, 1961. Papadakis, A. : Parasitology. Athens, Rodi Brothers. 1956, p. 443. Woolsey, G. : Cited by Morcos, W.M. Riv. Malar. 40: 41, 1961.</meta-value>
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               <name name-style="western"><surname>Belios, G.D.</surname>
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               <name name-style="western"><surname>Faust, E.C.</surname>
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, <name name-style="western"><surname>Shute, P.G.</surname>
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               <name name-style="western"><surname>Hutton, E.L.</surname>
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