Internal Medicine

0521779407-14 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:16

Malaria Malignant Tumors of the Liver 947

follow-up

■With appropriate treatment, fever should resolve in 48–72 h and par-

asitemia should be <25% of the original value 48 h after initiating

therapy.

■In non-immune patients with uncomplicated disease, repeat blood

smears daily until negative; repeat smears if fever recurs >48 h after

treatment.

■In severe cases, repeat blood smears frequently (every 6–12 h) until

patient stabilizes and then daily until negative.

■In all patients, repeat smears if fever recurs >48 h after treatment.

■Consider treatment failure and need for alternative therapy if evi-

dence of severe disease develops at any time during therapy; parasite

count at 48 h is >25% of original value; fever is present≥72 h and

blood smear is still positive; blood smear remains positive 7 days

after initiating therapy.

complications and prognosis

■Overall mortality in returning travelers:∼5%

■Cerebral malaria: mortality in 15–20%; neurologic sequelae more

common in children (>10%) than adults (5%)

■Renal failure: multifactorial but resembles acute tubular necrosis;

increases mortality risk; may require dialysis

■Pulmonary edema: associated with hyperparasitemia, uncommon

but frequently fatal (mortality >80%); resembles ARDS and may

require mechanical ventilation

■Hypoglycemia: occurs in 5–30% of patients with cerebral malaria;

more common in children, pregnant women, hyperparasitemia,

with quinine/quinidine therapy

■Late splenic rupture (P. vivax): uncommon, occurs after 2–3 months

■Immune complex glomerulonephritis (P. malariae): seen with

chronic or repeated infections; results in nephrotic syndrome

MALIGNANT TUMORS OF THE LIVER

EMMET B. KEEFFE, MD

history & physical

History

■metastases most common hepatic malignancy

■most frequent origin for hepatic metastases are lung, breast, and

gastrointestinal tract