广西壮族自治区1例输入性恶性疟死亡病例分析

Analysis of a fatal case of imported falciparum malaria in Guangxi Zhuang Autonomous Region

目的分析广西壮族自治区2023年1月1例恶性疟的死亡原因,为预防疟疾死亡病例发生提供参考。方法访谈接诊医生、会诊医生及患者家属,收集患者诊治过程的临床资料,对患者临床病历和流行病学调查资料进行分析。结果患者何某,男,53岁,广西壮族自治区贵港市平南县人,2022年12月26日自非洲科特迪瓦务工返乡入境,2023年1月3日解除集中隔离后返回家中。2023年1月4日患者出现头晕、呕吐,自认为感染新型冠状病毒未予处理,1月6日上午患者出现发热(体温峰值40℃),伴全身乏力、咽喉痛,原有症状加重,以“肺部感染”收治入官城镇卫生院,予利巴韦林、地塞米松、头孢曲松钠等治疗。1月7日患者再次出现高热(40℃),遂出院至广西医科大学第一附属医院急诊科就诊,入院时测血压78/53 mmHg,完善检查提示血小板下降,降钙素原49.9 ng/mL,肝肾功能异常,胸部CT提示肺炎,予积极抗休克、抗感染治疗。1月8日患者血涂片发现疟原虫,诊断为疟疾(未分型,后经复核为恶性疟),建议立即转诊至省级疟疾定点医院抗疟治疗,但患者家属拒绝。1月8日13:27患者解暗红色血便700 g,神志模糊,予积极止血治疗。后经多方协调,调取治疗用“注射用青蒿琥酯”4支(60 mg/支),于1月8日18:59静脉推注注射用青蒿琥酯60 mg,同时辅以退热及补液等对症治疗,19:40患者出现严重低血糖,严重代谢性酸中毒,血压在应用升压药情况下仍持续下降,1月9日凌晨3:00经综合治疗后患者休克仍无法纠正,神志昏迷,家属要求出院,7:00回到家中,7:30患者死亡。结论对于输入性疟疾,根据流行病学史、临床症状和实验室检查结果尽早明确诊断,尽早使用抗疟药治疗,积极处理器官功能障碍,是避免出现患者死亡的关键。

Objective To analyze the causes of death of one case of imported falciparum malaria in Guangxi Zhuang Autonomous Region in January 2023,to provide a reference for the prevention of fatal malaria cases.Methods Interviews were conducted with the doctors who received and consulted the patient,as well as the family members of the patient.Clinical data from the patient's diagnosis and treatment process were collected,and the patient's clinical records and epidemiological investigation data were analyzed.Results The patient,Mr.He,a 53-year-old male from Pingnan County,Guigang City,Guangxi Zhuang Autonomous Region,returned from working in Côte d'Ivoire,Africa,and entered Guangxi on December 26,2022.He returned home after his centralized quarantine was lifted on January 3,2023.On January 4th,2023,the patient developed dizziness and vomiting,considering himself to a possible COVID-19 infection,he did not seek treatment.On the morning of January 6,the patient developed a fever(peak body temperature of 40℃),accompanied by fatigue and sore throat,and the preemptive symptoms were aggravated.The patient was admitted to the Guancheng Town Health Center with"Pneumonia"and treated with ribavirin,dexamethasone,ceftriaxone sodium,etc.On January 7,the patient again experienced a high fever(40℃)and was discharged to the Emergency Department of the First Affiliated Hospital of Guangxi Medical University.Upon admission,the patient's blood pressure was measured at 78/53mmHg,further comprehensive examination showed a decrease in platelets and abnormalities in liver and renal function,procalcitonin levels at 49.9 ng/mL.Chest CT showed pneumonia,and fluid supplements and antibiotics were given.On January 8,malaria parasites were found in the patient's blood smear,and the patient was diagnosed with malaria(not classified,confirmed as falciparum malaria on January 9th).The patient was recommended to transfer to the provincial malaria-designated hospital,but his family refused.On January 8 at 13:27,the patient excreted approximately 700 g of dark red bloody stools accompanied by blurred consciousness and received hemostasis treatment.After coordinating with multiple parties,four doses of"artemisinin injection"(60 mg/dose)were taken for treatment.At 18:59 on January 8,intravenous administration of 60 mg injectable Artesunate was given,accompanied by symptomatic treatment for fever reduction and rehydration.At 19:40,the patient developed severe hypoglycemia,and severe metabolic acidosis,and blood pressure continued to decrease despite the use of vasopressors.After comprehensive treatment at 3:00 am on January 9,the patient's condition continued to deteriorate,the patient's shock could not be corrected,he lapsed into a coma,and the family requested to be discharged from the hospital.The patient returned home at 7:00 am and died of multiple organ failure at 7:30 am.Conclusions For imported malaria,early and precise diagnosis based on epidemiological history,clinical symptoms,laboratory test results,early antimalarial treatment,and management of organ dysfunction are the keys to avoiding fatal outcomes.