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Jajosky RP, Wu SC, Jajosky PG, Stowell SR. Plasmodium knowlesi ( Pk) Malaria: A Review & Proposal of Therapeutically Rational Exchange (T-REX) of Pk-Resistant Red Blood Cells. Trop Med Infect Dis 2023; 8:478. [PMID: 37888606 PMCID: PMC10610852 DOI: 10.3390/tropicalmed8100478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/09/2023] [Accepted: 10/12/2023] [Indexed: 10/28/2023] Open
Abstract
Plasmodium knowlesi (Pk) causes zoonotic malaria and is known as the "fifth human malaria parasite". Pk malaria is an emerging threat because infections are increasing and can be fatal. While most infections are in Southeast Asia (SEA), especially Malaysia, travelers frequently visit this region and can present with Pk malaria around the world. So, clinicians need to know (1) patients who present with fever after recent travel to SEA might be infected with Pk and (2) Pk is often misdiagnosed as P. malariae (which typically causes less severe malaria). Here we review the history, pathophysiology, clinical features, diagnosis, and treatment of Pk malaria. Severe disease is most common in adults. Signs and symptoms can include fever, abdominal pain, jaundice, acute kidney injury, acute respiratory distress syndrome, hyponatremia, hyperparasitemia, and thrombocytopenia. Dengue is one of the diseases to be considered in the differential. Regarding pathophysiologic mechanisms, when Pk parasites invade mature red blood cells (RBCs, i.e., normocytes) and reticulocytes, changes in the red blood cell (RBC) surface can result in life-threatening cytoadherence, sequestration, and reduced RBC deformability. Since molecular mechanisms involving the erythrocytic stage are responsible for onset of severe disease and lethal outcomes, it is biologically plausible that manual exchange transfusion (ET) or automated RBC exchange (RBCX) could be highly beneficial by replacing "sticky" parasitized RBCs with uninfected, deformable, healthy donor RBCs. Here we suggest use of special Pk-resistant donor RBCs to optimize adjunctive manual ET/RBCX for malaria. "Therapeutically-rational exchange transfusion" (T-REX) is proposed in which Pk-resistant RBCs are transfused (instead of disease-promoting RBCs). Because expression of the Duffy antigen on the surface of human RBCs is essential for parasite invasion, T-REX of Duffy-negative RBCs-also known as Fy(a-b-) RBCs-could replace the majority of the patient's circulating normocytes with Pk invasion-resistant RBCs (in a single procedure lasting about 2 h). When sequestered or non-sequestered iRBCs rupture-in a 24 h Pk asexual life cycle-the released merozoites cannot invade Fy(a-b-) RBCs. When Fy(a-b-) RBC units are scarce (e.g., in Malaysia), clinicians can consider the risks and benefits of transfusing plausibly Pk-resistant RBCs, such as glucose-6-phosphate dehydrogenase deficient (G6PDd) RBCs and Southeast Asian ovalocytes (SAO). Patients typically require a very short recovery time (<1 h) after the procedure. Fy(a-b-) RBCs should have a normal lifespan, while SAO and G6PDd RBCs may have mildly reduced half-lives. Because SAO and G6PDd RBCs come from screened blood donors who are healthy and not anemic, these RBCs have a low-risk for hemolysis and do not need to be removed after the patient recovers from malaria. T-REX could be especially useful if (1) antimalarial medications are not readily available, (2) patients are likely to progress to severe disease, or (3) drug-resistant strains emerge. In conclusion, T-REX is a proposed optimization of manual ET/RBCX that has not yet been utilized but can be considered by physicians to treat Pk malaria patients.
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Affiliation(s)
- Ryan Philip Jajosky
- Joint Program in Transfusion Medicine, Brigham and Women’s Hospital, Harvard Medical School, 630E New Research Building, 77 Avenue Louis Pasteur, Boston, MA 02115, USA; (S.-C.W.)
- Biconcavity Inc., Lilburn, GA 30047, USA
| | - Shang-Chuen Wu
- Joint Program in Transfusion Medicine, Brigham and Women’s Hospital, Harvard Medical School, 630E New Research Building, 77 Avenue Louis Pasteur, Boston, MA 02115, USA; (S.-C.W.)
| | | | - Sean R. Stowell
- Joint Program in Transfusion Medicine, Brigham and Women’s Hospital, Harvard Medical School, 630E New Research Building, 77 Avenue Louis Pasteur, Boston, MA 02115, USA; (S.-C.W.)
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Odedra A, Lalloo DG, Kennedy G, Llewellyn S, McCarthy JS. Safety and effectiveness of apheresis in the treatment of infectious diseases: A systematic review. J Infect 2019; 79:513-520. [PMID: 31622632 DOI: 10.1016/j.jinf.2019.09.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 09/25/2019] [Accepted: 09/27/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Apheresis has been used as adjunctive treatment of severe falciparum malaria, loiasis and babesiosis. This systematic review aimed to investigate the safety and efficacy of apheresis in the treatment of these conditions. METHODS MEDLINE, PUBMED, EMBASE and CINAHL databases were searched to identify studies published between January 1969 and March 2018 involving patients treated using apheresis for severe falciparum malaria, loiasis or babesiosis. Data extracted included details about the apheresis intervention, populations, study methods and outcomes relating to efficacy and safety. RESULTS A total of 67 publications met the inclusion criteria and were included in the data synthesis, 36 for malaria (70 cases), 17 for babesiosis (22 cases) and 14 for loiasis (34 cases). Publications were case reports, case series, and cohort studies; there were no randomised controlled trials identified. Potential publication bias was considered to be high. CONCLUSIONS Systematic review of the literature suggests that apheresis may be a useful adjunct in the treatment of patients hospitalised for babesiosis, and prior to chemotherapy in loiasis with microfilarial count >8000 parasites/mL. Data does not support the use of apheresis in patients with severe falciparum malaria.
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Affiliation(s)
- Anand Odedra
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston QLD 4006, Australia; Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK; Royal Brisbane and Women's Hospital, Butterfield Street, Herston QLD 4029, Australia.
| | - David G Lalloo
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Glen Kennedy
- Royal Brisbane and Women's Hospital, Butterfield Street, Herston QLD 4029, Australia
| | - Stacey Llewellyn
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston QLD 4006, Australia
| | - James S McCarthy
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston QLD 4006, Australia; Royal Brisbane and Women's Hospital, Butterfield Street, Herston QLD 4029, Australia
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Otrock ZK, Thibodeaux SR, Jackups R. Vascular access for red blood cell exchange. Transfusion 2018; 58 Suppl 1:569-579. [DOI: 10.1111/trf.14495] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Zaher K. Otrock
- Department of Pathology and Laboratory Medicine; Henry Ford Hospital; Detroit Michigan
| | - Suzanne R. Thibodeaux
- Department of Pathology and Immunology; Washington University School of Medicine; St. Louis Missouri
| | - Ronald Jackups
- Department of Pathology and Immunology; Washington University School of Medicine; St. Louis Missouri
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Varo R, Crowley VM, Sitoe A, Madrid L, Serghides L, Kain KC, Bassat Q. Adjunctive therapy for severe malaria: a review and critical appraisal. Malar J 2018; 17:47. [PMID: 29361945 PMCID: PMC5781278 DOI: 10.1186/s12936-018-2195-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 01/19/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Despite recent efforts and successes in reducing the malaria burden globally, this infection still accounts for an estimated 212 million clinical cases, 2 million severe malaria cases, and approximately 429,000 deaths annually. Even with the routine use of effective anti-malarial drugs, the case fatality rate for severe malaria remains unacceptably high, with cerebral malaria being one of the most life-threatening complications. Up to one-third of cerebral malaria survivors are left with long-term cognitive and neurological deficits. From a population point of view, the decrease of malaria transmission may jeopardize the development of naturally acquired immunity against the infection, leading to fewer total cases, but potentially an increase in severe cases. The pathophysiology of severe and cerebral malaria is not completely understood, but both parasite and host determinants contribute to its onset and outcomes. Adjunctive therapy, based on modulating the host response to infection, could help to improve the outcomes achieved with specific anti-malarial therapy. RESULTS AND CONCLUSIONS In the last decades, several interventions targeting different pathways have been tested. However, none of these strategies have demonstrated clear beneficial effects, and some have shown deleterious outcomes. This review aims to summarize evidence from clinical trials testing different adjunctive therapy for severe and cerebral malaria in humans. It also highlights some preclinical studies which have evaluated novel strategies and other candidate therapeutics that may be evaluated in future clinical trials.
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Affiliation(s)
- Rosauro Varo
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique. .,ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 5th Floor, 08036, Barcelona, Spain.
| | - Valerie M Crowley
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Antonio Sitoe
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique
| | - Lola Madrid
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique.,ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 5th Floor, 08036, Barcelona, Spain
| | - Lena Serghides
- Toronto General Research Institute (TGRI), University Health Network, Toronto, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, Canada.,Department of Immunology and Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Kevin C Kain
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Tropical Diseases Unit, Division of Infectious Diseases, Department of Medicine, UHN-Toronto General Hospital, Toronto, ON, Canada
| | - Quique Bassat
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique. .,ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 5th Floor, 08036, Barcelona, Spain. .,ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain. .,Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain.
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Gajović O, Stanojevic-Pirkovic M, Popovska-Jovicic B, Nesic L, Mijailovic Z, Cekerevac I, Susa R, Gavrilovic J. Life-Threatening Plasmodium Falciparum Malaria in Patient after Visiting Angola-Case Report. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2017. [DOI: 10.1515/sjecr-2016-0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Malaria is a potentially life-threatening disease, especially when complicated by a septic shock. It is caused by infection of erythrocytes with protozoan parasites of the genus Plasmodium that are inoculated into the humans by a feeding female anopheline mosquito. Of the four Plasmodia species, infection with Plasmodium (P.) falciparum is often associated with different types of complications and significant mortality. Most imported cases of malaria are not in tourists but in immigrants and their children who have returned to the country of their family’s origin to visit friends and relatives (so-called VFR travelers) and have forgone chemoprophylaxis.
We described a case of a 52 year old patient who came from Angola, an African country with endemic malaria before the occurrence of the first symptoms of the disease. The first symptoms were not recognized by the presence of nonspecific symptoms. Very soon the patient was gone under the hemodynamic unstability that eas followed by shock and high percentage parasitemia of 25%. A global health disorder was developed accompanied with hemodynamic instability and cerebral dysfunction. He performs pulmonary ventilation disorder and renal failure. Only data from social epidemiological survey of travel to the African country, was sufficient to cast doubt on malaria. The diagnosis was conducted using the standard method - peripheral blood smear. After turning antimalarial drugs, improvement of health status with complete recovery within 10 days was noticed. The only consequence of the disease is persistent hypertension that is sensitive to standard antihypertensive therapy.
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Affiliation(s)
- Olgica Gajović
- Clinical Centre Kragujevac, Clinic for Infectious Diseases, Kragujevac, Serbia
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Marijana Stanojevic-Pirkovic
- Clinical Centre Kragujevac, Clinic for Infectious Diseases, Kragujevac, Serbia
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Biljana Popovska-Jovicic
- Clinical Centre Kragujevac, Clinic for Infectious Diseases, Kragujevac, Serbia
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Ljiljana Nesic
- Clinical Centre Kragujevac, Clinic for Infectious Diseases, Kragujevac, Serbia
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Zeljko Mijailovic
- Clinical Centre Kragujevac, Clinic for Infectious Diseases, Kragujevac, Serbia
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Ivan Cekerevac
- Clinical Centre Kragujevac, Clinic for Pulmonology, Kragujevac, Serbia
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Romana Susa
- Clinical Centre Kragujevac, Clinic for Pulmonology, Kragujevac, Serbia
| | - Jagoda Gavrilovic
- Clinical Centre Kragujevac, Clinic for Infectious Diseases, Kragujevac, Serbia
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Daniel MJ, Muddegowda PH, Chezhiansubash, Lingegowda JB, Gopal N, Prasad K. Study of Twenty One Cases of Red Cell Exchange in a Tertiary Care Hospital in Southern India. J Clin Diagn Res 2016; 10:EC28-30. [PMID: 27437227 DOI: 10.7860/jcdr/2016/13427.7809] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 02/24/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Red Cell Exchange (RCE) is removal of a patient's red blood cells while replacing with donor red blood cells either manually or using automated systems. RCE is beneficial in patients with Sickle Cell Disease (SCD) either during sickling crisis or prior to major surgical procedures to bring down the sickling percentage as high sickling percentage during prolonged anaesthesia may lead to vaso-occlusive crisis. It is also employed in patients infested with malaria and babesiosis where parasitic index remain high despite medical management. RCE is also tried as an adjuvant therapy in certain poisons like nitrobenzene and carbon monoxide when first line management fails. AIM To study the effectiveness, clinical outcome, challenges and complications of RCE in various clinical scenario and to understand how this procedure can be effectively utilized in the management of patients in Indian scenario. MATERIALS AND METHODS This retro prospective study was conducted in tertiary care center in southern India which analyzed 21 RCE procedures performed on patients with different clinical conditions. Of the 21 RCE performed, 18 procedures were performed on patients with case of sickle cell disease, Two procedures were performed on patients infested with severe falciparum malaria and one procedure was performed on a patient with nitrobenzene poisoning. All procedures were performed using Spectra Optia(®) Apheresis System - Terumo BCT. RESULTS All the 18 patients who underwent the RCE for sickle cell anaemia were admitted for hemi-arthroplasty for avascular necrosis of the head of femur. The average initial HbS levels were between 73-85% and post RCE it was brought down to 22-29% and was achieved in a single sitting in all the cases. Among the two patients infested with severe falciparum malaria, RCE helped in reducing the infestation rate. In case of nitrobenzene poisoning, RCE helped in improvement of oxygen saturation and patient showed significant improvement. CONCLUSION RCE is an safe and clinically effective therapeutic modality with very minimal to nil side effects. RCE is possibly underutilized therapy in developing world like India due to various reasons like inadequate awareness/ technical expertise, lack of equipments and facilities to identify the clinical conditions per se etc.
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Affiliation(s)
- M Joshua Daniel
- Associate Professor, Department of Transfusion Medicine, Mahatma Gandhi Medical College and Research Institute , SBV, Pillaiyarkuppam, Puducherry, India
| | - Prakash H Muddegowda
- Associate Professor, Department of Pathology, VMKV Medical College , Seeragapadi, Salem, Tamil Nadu, India
| | - Chezhiansubash
- Consultant Hematologist, MIOT International Hospital , Chennai, India
| | - Jyothi B Lingegowda
- Associate Professor, Department of Pathology, VMKV Medical College , Seeragapadi, Salem, Tamil Nadu, India
| | - Niranjan Gopal
- Associate Professor, Department of Biochemistry, Mahatma Gandhi Medical College and Research Institute , SBV, Pillaiyarkuppam, Puducherry, India
| | - Krishna Prasad
- Lt col- Graded Specialist Anesthesia, AMC , 425 FD Hospital, Poonch
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Marques MB, Singh N, Reddy VV. Out with the bad and in with the good; red cell exchange, white cell reduction, and platelet reduction. J Clin Apher 2014; 29:220-7. [DOI: 10.1002/jca.21332] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 05/01/2014] [Indexed: 01/08/2023]
Affiliation(s)
- Marisa B. Marques
- Department of Pathology; University of Alabama at Birmingham; Birmingham Alabama
| | - Nirupama Singh
- Department of Pathology; University of Alabama at Birmingham; Birmingham Alabama
| | - Vishnu V.B. Reddy
- Department of Pathology; University of Alabama at Birmingham; Birmingham Alabama
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Auer-Hackenberg L, Winkler S, Graninger W, Worel N, Ramharter M. Current evidence and future of automated erythrocyte exchange in the treatment of severe malaria. Wien Klin Wochenschr 2012; 124 Suppl 3:23-6. [PMID: 23064860 DOI: 10.1007/s00508-012-0238-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2012] [Accepted: 08/06/2012] [Indexed: 12/15/2022]
Abstract
Despite the administration of antimalarial treatment, severe malaria still has a high mortality rate. Since overall survival is associated with total parasite biomass, whole blood exchange (e.g. blood exchange transfusions) has been proposed as a potential method to rapidly reduce peripheral parasitaemia. Automated red blood cell exchange has been advocated as a physical method to remove parasites. Compared to exchange transfusion, automated red blood exchange may avoid the risk of volume alterations and haemodynamic distress. Since 1984, there have been 37 published cases in which automated red blood cell exchange was used as an adjunctive treatment in severe malaria caused by Plasmodium falciparum. This short review summarizes current evidence and discusses problems, challenges and goals for future studies and research in order to assess the clinical benefit of automated erythrocyte exchange in severe malaria cases.
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Affiliation(s)
- Lorenz Auer-Hackenberg
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1190 Vienna, Austria
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Auer-Hackenberg L, Staudinger T, Bojic A, Locker G, Leitner GC, Graninger W, Winkler S, Ramharter M, Worel N. Automated red blood cell exchange as an adjunctive treatment for severe Plasmodium falciparum malaria at the Vienna General Hospital in Austria: a retrospective cohort study. Malar J 2012; 11:158. [PMID: 22564543 PMCID: PMC3447647 DOI: 10.1186/1475-2875-11-158] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 05/07/2012] [Indexed: 12/12/2022] Open
Abstract
Background Severe falciparum malaria is associated with considerable rates of mortality, despite the administration of appropriate anti-malarial treatment. Since overall survival is associated with total parasite biomass, blood exchange transfusion has been proposed as a potential method to rapidly reduce peripheral parasitaemia. However, current evidence suggests that this treatment modality may not improve outcome. Automated red blood cell exchange (also referred to as “erythrocytapheresis”) has been advocated as an alternative method to rapidly remove parasites from circulating blood without affecting patients’ volume and electrolyte status. However, only limited evidence from case reports and case series is available for this adjunctive treatment. This retrospective cohort study describes the use of automated red blood cell exchange for the treatment of severe malaria at the Medical University of Vienna. Methods Epidemiologic data for imported malaria cases in Austria are reported and data of patients treated for malaria at the General Hospital/Medical University of Vienna were extracted from electronic hospital records. Results Between 2000 and 2010, 146 patients were hospitalized at the Medical University of Vienna due to malaria and 16 of those were classified as severe malaria cases. Eleven patients of this cohort were potentially eligible for an adjunctive treatment with automated red blood cell exchange. Five patients eventually underwent this procedure within a period of seven hours (range: 3–19 hours) after hospital admission. Six patients did not undergo this adjunctive treatment following the decision of the treating physician. The procedure was well tolerated in all cases and rapid reduction in parasite counts was achieved without occurrence of haemodynamic complications. One patient died within seven days, whereas four patients survived without any sequelae. Discussion and conclusion Automated red blood cell exchange was a safe and efficient procedure to rapidly clear peripheral parasitaemia. Whether the fast reduction in parasite biomass may ultimately improve patient survival remains however unclear. Randomized controlled trials are needed to conclusively appreciate the value of this adjunctive treatment.
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Affiliation(s)
- Lorenz Auer-Hackenberg
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1190, Vienna, Austria
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