Multiresistant malaria in Brazil cured with low dose clindamycin

doi:10.1590/S0036-46651988000200012

LETTER TO THE EDITOR

We report a case of multidrug resistant P. falciparum finally cured with a low dose regimen of clindamycin.

A 26 year old male patient (54 kg body weight) was admitted with fever and headache to the SUCAM outpatient clinic in Rio Branco. Acre state, Brazil. The patient recently immi grated from a malaria free area in the South of Brazil to Amazonia. This was his first attack and he denied taking any medication during the pre ceding four weeks. Amodiaquine treatment was started after diagnosis of P. falciparum infection (parasitaemia: 45.150 asexual parasites μl blood). 600 mg of amodiaquine base was given on day zero, 450 mg on day 1 and day 2 each. No vomiting occurred. Daily parasite counts and cli nical examination were performed. On day 2 the symptoms ceased and parasitaemia was 4.665>1. Parasitaemia further decreased to 24/μl on day 7 (resistance grade II). The oral quinine treatment was administered 500 mg qui nine sulfate twice a day for 10 days. Daily thick blood smears and clinical examinations were performed during the treatment period. Within 48 hours after starting quinine treatment no more parasites could be detected. During therapy the patient developed nausea and tinnitus, but he did not vomit. Two and three weeks after start of quinine therapy the patient felt well and no parasites could be seen in thick blood smears. But four weeks after quinine administration he presented fever with 38.8"C and nausea. Thick blood smears again were P. falciparum positive (35.640/μl). We gave an oral combination of qui nine plus clindamycin. Quinine was administered as shown above for three days and simulta neously 600 mg clindamycin twice a day for three days. Again daily checks were done in the first week. Fever and symptoms ceased two days af ter starting treatment and two days more parasi taemia cleared. Self limiting, mild side effects were dizziness and diarrhoea. After the first week following quinine clindamycin therapy weekly checks were made. Asymptomatic recrudescen ce was detected four weeks after the treatment (2.088 asexual parasites /ul). At this time the pa tient presented with splenomegaly. We decided to give oral clindamycin alone in a lower dosage but a longer course of 300 mg twice a day for five days to avoid diarrhoea. No side effects oc curred. Parasitaemia cleared seven days after initiation of treatment and for the following five weeks parasitaemia did not recrudesce. After the first diagnosis of malaria and during the subse quent period of treatment the patient stayed in Rio Branco, where no natural malaria transmis sion occurred (R. M. ROCHA, personal commu nication). A reinfection was therefore impossi ble. We conclude that clindamycin even in a low dose can be considered as an effective alterna tive treatment for multidrug resistant malaria in Brazil.

Institute of Tropical Medicine P. G. KREMSNER

Konigin-Elisabeth-Strasse 32.

D-1000 Berlin 19, FRG.

H. FELDMEIER SUCAM Acre, Brazil R. M. ROCHA Department of Chemotherapy, University of Vienna, Austria W. GRANINGER

EDITORIAL BOARD NOTE:

This is a preliminary result in which there is lack of drug quantification and "in vitro" patient strain drug tests. More research work is needed including controlled drug trials in large population before a definitive acceptance of this therapy However, there is in this preliminary report valuable clinical information in respect to P. falciparum multiresistant drug, treatment.

Recebido para publicação em 4/4,1988.

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