Further Outpatient Care
Regular visits are essential to monitor the patient's clinical improvement and to document decreases in splenomegaly.
If chloroquine is used, monitor the patient for ophthalmologic effects with slit lamp, funduscopic, and visual field examinations.
At regular intervals, perform cardiovascular monitoring with ECG and echocardiography, along with other tests as indicated.
Further workup may be indicated to look for myopathy and peripheral neuritis.
Liver function tests may be performed regularly if the patient is receiving proguanil.
Resolution of splenomegaly is accompanied by an improvement of pancytopenia.
Further Inpatient Care
Because of the extended length of treatment often needed for hyperreactive malarial splenomegaly (HMS), monitoring for adverse effects is crucial.
Splenectomy is contraindicated, because of increased infection-associated mortality. However, if the patient's spleen was previously removed, guidelines for the care of asplenic patients should be followed (see Asplenia). Guidelines include the following:
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Antibiotic prophylaxis
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Education
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Aggressive management of suspected episodes of fever
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Appropriate immunizations
Inpatient & Outpatient Medications
Antimalarials are the mainstays of treatment for hyperreactive malarial splenomegaly (HMS) (see Medication). These drugs often need to be continued long-term (months to years). However, the exact length of treatment has not been ascertained.
Transfer
Depending on the facilities available at the hospital, indications for transfer may be few. Medication can easily be started after the diagnosis is established. Supportive care, including blood transfusions and antibiotic therapy if indicated, is now commonplace in most hospitals.
Deterrence/Prevention
For travelers to endemic areas, antimalarial prophylaxis is essential to minimize the risk of hyperreactive malarial splenomegaly (HMS).
Prophylaxis for residents of endemic areas is controversial and has not been shown to prevent HMS.
A study in Africa determined that the RTS,S/AS02D malaria vaccine was safe, well tolerated, and immunogenic in young infants. [37] A recent report of a phase 3 trial of RTS,S/AS01 malaria vaccine showed modest protection (50% reduction) against clinical and severe malaria in African infants. [38]
Long-term follow-up and studies are needed on whether a reduction in incidence of acute infection will lead to a decrease in the incidence of HMS. [32]
Complications
Complications of hyperreactive malarial splenomegaly (HMS) include infections that may be serious and that may result in death. Trapping of hematopoietic elements in the enlarged spleen may cause thrombocytopenia, anemia, and neutropenia, with resultant problems.
A predisposition to develop malignancy remains unproven.
A study by Zambrano et al looking at unresolved HMS in Congolese refugees recently resettled in the United States reported that the likelihood of a hematologic abnormality, including anemia, thrombocytopenia, or leukopenia, was 39% greater in those who had splenomegaly at any time after arrival. Moreover, in persons with persistent splenomegaly, there was a 60% greater chance of a hematologic abnormality, especially thrombocytopenia (five-fold higher risk), with elevated alkaline phosphatase also being found (57% greater likelihood). [39]
Prognosis
Hyperreactive malarial splenomegaly (HMS) is a chronic disease with mortality rates from 20-57% based on the degree of splenomegaly. [17] Higher mortality rates are associated with treatment noncompliance. [18] Bleeding and infection are the most common complications. [17]
Splenectomy should be avoided because it increases the risk of fulminant infections.
The exact risk of development of malignancy has not been established.
Patient Education
The importance of antimalarial prophylaxis during visits to endemic areas should be emphasized to travelers.
Symptoms should be promptly attended to and evaluated, even if they occur in travelers who received prophylaxis. Hyperreactive malarial splenomegaly (HMS) may present months to years after leaving an endemic area.
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Young patient with hepatomegaly and massive splenomegaly.
