Year : 2019 | Volume
: 4 | Issue : 1 | Page : 39--41
Complicated Plasmodium vivax infection with malarial hepatopathy and splenic abscess
Priya Bansal, Ankit Gupta, Ravi Meena
Department of Medicine, LHMC and SSK Hospital, New Delhi, India
Dr. Priya Bansal
R - 4/44 Raj Nagar, Ghaziabad - 201 002, Uttar Pradesh
Malaria is a serious health burden in the tropical countries. Jaundice is a known manifestation of complicated falciparum malaria but is unusual with Plasmodium vivax infection. Only a few cases of vivax malarial hepatopathy have been reported till date. Here, we present a rare case of vivax malaria hepatopathy with secondary splenic abscess. No such case of dual complications of vivax malaria in the same patient has been reported till date to the best of our knowledge.
|How to cite this article:|
Bansal P, Gupta A, Meena R. Complicated Plasmodium vivax infection with malarial hepatopathy and splenic abscess.BLDE Univ J Health Sci 2019;4:39-41
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Bansal P, Gupta A, Meena R. Complicated Plasmodium vivax infection with malarial hepatopathy and splenic abscess. BLDE Univ J Health Sci [serial online] 2019 [cited 2020 Jul 4 ];4:39-41
Available from: http://www.bldeujournalhs.in/text.asp?2019/4/1/39/260730
Malaria is caused by the parasite Plasmodium. The species responsible for infection in humans are Plasmodium vivax, Plasmodium falciparum, Plasmodium malariae, Plasmodium ovale, and Plasmodium knowlesi. Patients usually present with high-grade fever with chills and rigor, body ache, malaise, and reduced appetite. Jaundice as a symptom of malarial infection is reported to be only 2.58%. It results from hemolysis or direct hepatic involvement. It is more commonly seen with falciparum infection. Jaundice is also reported with P. vivax with incidence from 0% to 9%. However, direct hepatic involvement has rarely been described.,,
A diagnosis of malarial hepatitis or malaria “hepatopathy” is made if a patient fulfills the following criteria:,
Demonstration of the parasite (P. falciparum or P. vivax)A minimum 3-fold rise in serum transaminases (especially alanine transaminase [ALT]) seen in two samples and taken 24 h apart. Conjugated hyperbilirubinemia may or may not be presentAbsence of clinical or serological evidence of other causes of hepatitis including virusesResponse of hepatitis to antimalarial drugs.
Our patient has been diagnosed to be a case of vivax malaria hepatopathy.
In this case, malaria was also complicated by the presence of splenic abscess, a rare clinical entity. The incidence of splenic abscess is in the range of 0.14%–0.7%, and it has a high mortality rate. In malaria, changes in the spleen structure may be simple with only an asymptomatic enlargement or serious complications such as hematoma, rupture, or infarction may be seen. Hematoma or infarction may lead to the development of splenic abscess. Splenic abscess has been reported in falciparum malaria but rarely with vivax malaria.,, Its presence portends a grave prognosis for the patient and should be diagnosed and treated in time.
A 25-year-old nonpregnant female presented to the hospital emergency in October 2019 with a complaint of intermittent high-grade fever for 7 days. Each paroxysm was associated with chills and rigor and was relieved with profuse sweating. She also complained of malaise, with yellowish discoloration of eyes and urine for the same duration. It was associated with two episodes of vomiting, which was nonprojectile, nonbilious, and pain abdomen, in epigastric and left hypochondriac region, nonradiating. She denied any history of diarrhea, burning micturition, rashes, cough, or bleeding from any site.
On physical examination, she was hemodynamically stable (pulse – 110 beats/min, regular normal volume; blood pressure – 110/70 mmHg). Pallor and icterus were present. There was no evidence of cyanosis, clubbing, lymphadenopathy, and edema. The abdominal examination revealed palpable spleen, 3 cm below the left costal margin, smooth surface and firm in consistency. The liver was palpable 2 cm below the right costal margin in mid-clavicular line, with smooth surface and a well-defined margin. There was no shifting dullness, and bowel sounds were present. Examination of central nervous system, cardiovascular system, and respiratory system were unremarkable.
On investigations, the patient had the following results – hemoglobin – 9.5 g/dL, total leukocyte count (TLC) – 4900/dl, differential leukocyte count: neutrophils – 66%, lymphocytes – 28%, platelet count – 17000/dl, ALT – 130, aspartate transaminase – 118, total bilirubin – 16.2 mg/dL, and direct bilirubin – 8.0 mg/dL; card test for malaria antigen was positive for P. vivax. Peripheral smear showed that red blood cells were normocytic normochromic and showed mild anisocytosis, thrombocytopenia, and P. vivax trophozoites. Parasite density was, however, not calculated. Widal test was negative. Blood culture was sterile. The chest X-ray revealed no abnormality. She was treated with antimalarials (artesunate) and supportive therapy. She became symptomatically better and afebrile within a day. Her liver enzymes also showed improvement.
Even after 2 days of treatment, the patient's discomfort in the left hypochondriac persisted. Tenderness was present in the left hypochondriac with splenomegaly (4 cm below the left costal margin). TLC was 17,200/dL. Ultrasound sonography (USG) of the abdomen showed splenic abscess of size 4.6 cm × 1.6 cm. She was started on broad-spectrum antibiotics, which was followed by resolution of the patient's symptoms over a period of 1 week. She was continued on the antibiotics for 10 days. Review USG abdomen showed resolving abscess. TLC came down within normal range over a week.
Malaria due to P. vivax infection has been addressed as benign tertian malaria since the disease has been in study. It rarely caused organ involvement and was more often than not treated on outpatient basis with oral drugs. Increasingly, this benign vivax tertian malaria is emerging as a “malignant” disease. Malaria can act as “the great masquerader.” Physicians practicing in endemic areas should have a high degree of suspicion for malaria in patients with atypical fever patterns or manifestations.
Derangement of liver function tests is a common complication of malarial infection. “Malarial hepatopathy” describes the hepatic dysfunction in severe malarial infection more appropriately, and the term “malarial hepatitis” may be a misnomer. The presence of elevated hepatic enzymes and near-normal coagulation profile, with documented malarial infection should suggest associated malarial hepatopathy. While it is commonly seen in falciparum malaria, our case describes this as an atypical presentation of vivax infection.
Splenomegaly is frequently seen in malaria. It does not receive any special attention, as it is usually asymptomatic and gradually resolves following treatment with antimalarials. If the splenomegaly is complicated by torsion, abscess, or rupture, it may prove to be fatal. The known causes of splenic abscess are bacterial endocarditis, trauma with hematoma formation, and sickle cell or leukemia crisis.
In our case, splenomegaly was attributed to vivax infection, but fever and left hypochondriac pain persisted despite antimalarial therapy. The splenomegaly had not resolved. A possibility of secondary splenic infection was considered. In malaria, splenic microinfarcts and hematomas may occur due to altered hematological and coagulation parameters. Due to poor cellular and humoral immunity during infection, these may become complicated by secondary bacterial infection. Optimal treatment approach to splenic abscess is not well defined; however, there is consensus for a conservative management. This includes initial antibiotic treatment and as required catheter drainage. Our patient responded to broad-spectrum antibiotic treatment.
In a similar case reported by Tomar et al., a diabetic patient with diagnosed vivax malaria had splenomegaly, which was also complicated by splenic abscess due to Escherichia coli. This abscess was successfully managed by catheter drainage and antibiotic treatment. Before this, splenic abscess has been reported only in falciparum malaria. A 21-year-old female in Sierra Leone with a history of recurrent attacks of malaria over 2 months presented with persistent abdominal pain and episodes of spiking fever and was diagnosed to have splenic abscess on exploratory laparotomy. The patient eventually required splenectomy. Malaria in pediatric patients is complicated by splenic abscess more frequently than adults.,,,
Severe hepatic involvement in malaria is usually a result of concomitant viral infection or underlying chronic hepatitis. Patients with malarial hepatopathy have a better outcome than those with other causes of hepatic failure and should be promptly recognized and aggressively treated. The hepatitis improves after the resolution of fever and parasite clearance from the body following antimalarial treatment. No long-term residual effects have been seen following recovery.
If fever in malaria does not respond to antimalarial therapy, and if there is associated persistent left hypochondriac discomfort, a timely ultrasonography may reveal a splenic abscess. Discovery of this condition radically alters the patient management, the failure of which may be fatal.
In summary, our case of P. vivax infection is worth highlighting because a historically benign disease presented with dual complications of malaria hepatopathy and splenic abscess. The complications were treated in time, and the patient recovered completely in due course.
The limitation of our study is that the abscess could not be aspirated for culture, due to negative consent given by the patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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