Case Report Pulmonary Edema in Malaria Amar Safdar, MD;* Barry J. Hartman, MD;+ Bradley A. Connor, MD;+ and Henry W Murray, MD+ Two patients, hospitalized in NewYork City with malaria caused by Plasmodium falciparum, developed pul- monary edema while responding to antimalarial therapy. These cases serve as a timely reminder of this serious pulmonary complication of malaria. CASE REPORTS Patient 1 A 33-year-old Australian woman, who had been stationed in Liberia for 4 months, flew to New York City for vaca- tion. Several days later, she developed fever, rigors, lower back pain, and headache. On the third day of symptoms, she was acutely ill and was admitted to The New York Hospital where a peripheral blood smear showed char- acteristic ring forms of Pfalciparum (Figure 1). She had discontinued chloroquine and proguanil prophylaxis due to gastrointestinal intolerance 10 weeks before admis- sion. Initial laboratory studies included white blood cell (WBC) count of 4800/mm3; hemoglobin, 11.9 g/dL; hema- tocrit, 34%; platelet count, 43,000/mm3; lactic dehydro- genase (LDH), 399 IU; prothrombin time (PT), 14.7 seconds (control 12.0 s); and partial thromboplastin time m, 35.1 seconds (control 38 s). Admission chest exam- ination and roentgenogram were normal (Figure 2, A). After 18 hours of treatment with oral quinine and doxycycline, parasitemia was reduced from 2. ILto 1.2%. However, 12 hours later, the patient developed acute res- piratory distress with severe hypoxemia (arterial PO, 38 mmHg breathing room air). Bronchial breath sounds and rales were heard over both lower lung fields. Fever to 39°C persisted, although parasitemia was less than 0.1%. The patient developed evidence suggesting coagu- lopathy or disseminated intravascular coagulation (DIG) with a further increase in PT to15.4 seconds and a pos- itive D-dimer test. Repeat chest x-ray was consistent with *Department of Medicine, Memorial Sloan-Kettering Cancer Center and *Department of Medicine, New York Hospital-Cornell Medical Center, New York, New York. Address correspondence to Dr. Amar Safdar, Fellow, Infectious Disease Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 1002 1. E-mail: safdara@mskcc.org. pulmonary edema (see Figure 2, B). In the 24 hours prior to the onset of respiratory distress, the patient had received normal saline intravenously at a rate of 150 cc per hour. Serial electrocardiograms (EKG), cardiac enzymes, transthoracic echocardiogram, and a ventilation- perfusion scan were all normal. Although the patient had no clinical evidence of fluid overload, she received furosemide and responded with a diuresis of 2 liters of urine over 24 hours. Despite this, there was essentially no improvement in oxygenation (arterial PO,, 63 mmHg, while receiving 100% oxygen). Two days later clinical and radiographic findings began to improve and evidence of coagulopathy began to resolve. Antimalarial therapy was stopped after 7 days, and the patient was discharged on day 8 with a normal chest roentgenogram. Patient 2 A 35-year-old French-Haitian woman, who lived in New York City, presented to The New York Hospital with 2 days of high fever (4O”Q rigors, drenching sweats, and headache. Her symptoms started 7 days after a 5-day trip Figure 1. Giemsa-stained admission peripheral blood smear. Arrows indicate characteristic intra-etythrocytic ring and multiple appliqu6 forms (merozoites) of P falciparum. 217