A 33-year-old woman, born in Jacareí and residing in São Paulo, admitted with daily afternoon fever, asthenia, vomiting, myalgia, headache, dark urine, and decreased level of consciousness with 8 days of evolution. She reports travel to Nigeria (Lagos and Osogbo) for 14 days, staying in an urban area, where she participated in religious rituals with an animal (goat), drank only filtered water and cooked food. She returned to Brazil 18 days before the onset of symptoms. She denies contact with domestic animals or risky sexual exposures. Rapid tests and serologies for arboviruses, HIV, hepatitis, toxoplasmosis, CMV, EBV, rubella, and typhoid fever were performed with negative results. Thick smear confirmed Plasmodium falciparum, with parasitemia of 45,060 trophozoites and 120 gametocytes per field. Therapy with intravenous artesunate and clindamycin was initiated for 5-days and a single oral dose of primaquine, with parasitemia clearance after the third smear. On the fourth day of hospitalization, she evolved with acute respiratory failure and need for orotracheal intubation. Chest CT showed diffuse ground-glass opacities, bilateral consolidations, and pleural effusion, compatible with pulmonary vascular leakage. After failure of broad-spectrum antibiotic therapy, methylprednisolone 40 mg IV every 8 hours was initiated, with favorable clinical response, extubation in three days, and hospital discharge after five. Acute respiratory distress syndrome associated with malaria is an uncommon but severe manifestation of Plasmodium spp. infection, often associated with high morbidity and mortality. Experimental evidence points to a central role of cytokine- and chemokine-mediated pulmonary inflammation, with involvement of CD8⁺ T lymphocytes and macrophages in worsening the condition. Studies in murine models demonstrate that high-dose dexamethasone is capable of reducing cellular recruitment and the expression of inflammatory mediators such as MCP-1, with improvement of clinical findings. This report, with a favorable outcome after adjuvant corticosteroid use in MA-ARDS, reinforces the hypothesis of potential benefit in specific pulmonary contexts. These findings suggest that judicious use of corticosteroid therapy may be considered in selected situations, supported by individualized assessment and rigorous monitoring. Conducting controlled clinical studies is essential to better define the role of corticosteroids in the management of malaria with severe pulmonary involvement.
Vaz-Curado et al. (Sun,) studied this question.