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Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 31-32

Severe Complicated Plasmodium vivax Malaria: A Case Report

Department of General Medicine, MGM Medical College, Navi Mumbai, India

Date of Web Publication30-Apr-2019

Correspondence Address:
Dr. Kanishka Kumar
105 staff quarters, MGM Medical College, Navi Mumbai
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mamcjms.mamcjms_4_19

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Complicated malaria as defined by the World Health Organization was always understood to be caused by Plasmodium falciparum. Reports of Plasmodium vivax causing complicated cases have been emerging. This is to report one such case that was complicated by myocarditis and acute respiratory distress syndrome.

Keywords: ARDS, malarial myocarditis, P vivax malaria

How to cite this article:
Kumar K, Thakkar M, Rajge H, Khan A. Severe Complicated Plasmodium vivax Malaria: A Case Report. MAMC J Med Sci 2019;5:31-2

How to cite this URL:
Kumar K, Thakkar M, Rajge H, Khan A. Severe Complicated Plasmodium vivax Malaria: A Case Report. MAMC J Med Sci [serial online] 2019 [cited 2020 Jul 9];5:31-2. Available from: http://www.mamcjms.in/text.asp?2019/5/1/31/257424

  Introduction Top

Malaria caused by Plasmodium (P) vivax was usually understood to be benign in nature compared to the severe complicated varieties caused by P falciparum. However, in recent times, the infection caused by P vivax is also presenting with complicated features such as acute respiratory distress syndrome (ARDS), cardiogenic shock, thrombocytopenia, acute kidney injury, and severe anemia. There have been reports of P vivax presenting with complications.[1],[2] This report highlights one such case presented with myocarditis, shock, acute kidney injury, and ARDS.

  Case Report Top

A 40-year-old male patient presented to our hospital with complaints of fever with chills, body ache, generalized weakness, and multiple joint pain since 3 days.

At admission, the patient had no comorbidities. He was febrile (102°F), conscious, and oriented. The pulse rate was 88/min, regular, and low in volume. The systolic blood pressure was 80 mm Hg and the respiratory rate was 20/min.

Chest, cardiovascular, and abdominal examination were within normal limits.

A differential diagnosis of malaria, dengue, or viral fever was made and treatment with fluid resuscitation for blood pressure was started. Blood samples were promptly sent for complete blood count, malaria parasite, dengue NS1, leptospirosis, blood culture, and kidney and liver function tests. An electrocardiography was also obtained along with an X-ray of the chest.

The initial tests revealed hemoglobin (Hb) 14.6, total leucocyte count (TLC) 10,690, and platelets 60,000.

P vivax was found positive on antigen test and ring forms of trophozoites and schizont of P vivax were seen.

Dengue NS1 immunoglobulin M (IgM) and immunoglbulin G (IgG) were negative. Blood test for leptospirosis was found negative. Liver function test revealed serum bilurubin to be 2.08. Kidney function test revealed serum creatinine to be 2.13. X-ray chest was found to be normal.

Cardiac enzymes were sent in view of low blood pressure that showed mildly elevated troponin levels of 38.180 ng/L (normal less than 14) and creatinine phospho kinase muscle/brain (CPK MB) 61 IU/L (normal levels 0­–25­­).

The treatment of malaria was started in the form of injectable artesunate. On the next day, however, the patient’s blood pressure remained low and he started to have ectopic atrial beats alternating with sinus arrhythmias. The troponin levels were repeated that jumped to 851.700 ng/L and CPK to 82 IU/L. Patient’s echocardiography showed poor wall motion globally with left ventricular ejection fraction 38%.

A decrease in saturation followed by a fall in arterial oxygen tension/fractional inspired oxygen concentration ratio led to institution of mechanical ventilation. Chest had coarse crepitations and chest X-ray showed bilateral para-hilar shadows.

A diagnosis of complicated P vivax malaria causing myocarditis, acute kidney injury, ARDS and liver dysfunction, was made and inotropic support with noradrenaline and dopamine were started. Broad spectrum antibiotics were also added. The patient showed a response to treatment and ventilatory support was taken off.

The review echocardiography showed improved wall motion. The urine output and kidney and liver function tests recovered well. The patient was discharged and asked to follow-up in the outpatient department.

  Discussion Top

Complicated malaria is defined by the occurrence of cerebral malaria, acute renal failure, hepatic dysfunction, ARDS, anemia, and metabolic acidosis. It was originally understood to be a result of P falciparum infection. However, there have been a number of case reports wherein patients with P vivax malaria have suffered such complications.[1],[2],[3],[4],[5],[6],[7] The mechanism of injury is understood to be similar to P falciparum infections in which inflammatory responses and sequestration of parasitized red cells in the microcirculation was found to be the main culprit. Andrade et al.[8] found a strong linear trend between increased levels of C-reactive protein, tumour necrosis factor (TNF)-alpha, Interferon (IFN)-gamma, IFN-gamma/IL-10 ratio, and the disease severity of P vivax malaria. Price et al.[9] reported that the plasma concentrations of TNF-alpha are higher in P vivax as compared to P falciparum malaria.

Limaye et al.[1] in their study had seen 680 cases of malaria of which 338 were P vivax. Severe disease was found in 15% of the cases. The complications reported included thrombocytopenia (68%), severe anemia (2.37%), acute renal failure in 3.55%, and ARDS in 3%; cerebral involvement, which is rarely reported in P vivax, was seen in 12 patients out of which three had convulsions. Hypotension at presentation was present in 5.32%.[1]

Kochar et al.[2] for more than 2 years, studied a total of 1091 adults with malaria of which 456 had P vivax malaria. Complications observed were hepatic dysfunction and jaundice in 23 (57.5%) patients, renal failure in 18 (45%) patients, severe anemia in 13 (32.5%) patients, cerebral malaria in 5 patients (12.5%), ARDS in 4 patients (10%), shock in 3 patients (7.5%), and hypoglycemia in 1 (2.5%) patient. Thrombocytopenia was observed in five (12.5%) patients, and multiorgan dysfunction was detected in 19 (47.5%) patients.[2] Case reports of P vivax causing myocarditis are also reported.[10],[11]

Reports and studies have been of patients who have presented with a complication; however, myocarditis, ARDS, acute kidney injury, hepatic dysfunction, thrombocytopenia, and anemia occurring in the same patient have been reported rarely.

This case highlights that P vivax malaria can present with florid complications requiring intensive treatment.

  Conclusion Top

P vivax malaria earlier known as benign malaria is not always so and can present with multiple complications. Early diagnosis and treatment is important.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Limaye CS, Londhey VA, Nabar ST. The study of complications of vivax malaria in comparison with falciparum malaria in Mumbai. J Assoc Physicians India 2012;60:15-7.  Back to cited text no. 1
Kochar DK, Das A, Kochar SK, Saxena V, Sirohi P, Garg S et al. Severe Plasmodium vivax malaria: a report on serial cases from Bikaner in northwestern India. Am J Trop Med Hyg 2009;80:194-8.  Back to cited text no. 2
Barcus MJ, Basri H, Picarima H, Manyakori C, Sekartuti XX, Elyazar I et al. Demographic risk factors for severe and fatal vivax and falciparum malaria among hospital admissions in northeastern Indonesian Papua. Am J Trop Med Hyg 2007;77:984-91.  Back to cited text no. 3
Tjitra E, Anstey NM, Sugiarto P, Warikar N, Kenangalem E, Karyana M et al. Multidrug-resistant Plasmodium vivax associated with severe and fatal malaria: a prospective study in Papua, Indonesia. PLoS Med 2008;5:e128.  Back to cited text no. 4
Gera C, Dhanoa J. Vivax-induced ARDS: report of two cases. J Assoc Physicians India 2010;58:48-50.  Back to cited text no. 5
Sarkar S, Saha K, Das CS. Three cases of ARDS: an emerging complication of Plasmodium vivax malaria (Case report). Lung India 2010;27:154-7.  Back to cited text no. 6
[PUBMED]  [Full text]  
Tan LK, Yakoub S, Scott S, Bhagani S, Jacob M. Acute lung injury and other serious complications of Plasmodium vivax malaria. Lancet Infect Dis 2008;8:449-54.  Back to cited text no. 7
Andrade B, Reis-Filho A, Souza-Neto SM. Severe Plasmodium vivax malaria exhibits marked inflammatory imbalance. Malaria J 2010;9:13.  Back to cited text no. 8
Price RN, Tjitra E, Guerra CA. Vivax malaria: neglected and not benign. Am J Trop Med Hyg 2007; 77(6suppl):79-87.  Back to cited text no. 9
Kumar S, Behera S, Khan AA. Malarial myocarditis: a rare complication of Plasmodium vivax: Case report. J Clin Case Rep 2017;7:945.  Back to cited text no. 10
Gupta N, Sahoo SK. Plasmodium vivax induced myocarditis: a rare case report. Indian J Med Microbiol 2013;31:180-1.  Back to cited text no. 11
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