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Case Report
Acute severe pancreatitis in falciparum malaria Mrinal Kanti Taye, Dilip Kumar Saloi, Bikash Choudhury1 Departments of Anaesthesiology and Critical Care and 1Gastroentrology, Gauhati Medical College and Hospital, Guwahati, Assam, India
ABSTRACT
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Though different organs have been involved in falciparum malaria, pancreas has not been a common organ involved so far. Pancreatitis is a rare complication of Plasmodium falciparum malaria. The patient was admitted with low Glasgow Coma Scale and was febrile and in hypotension, and with oral bleeding. Preliminary investigations revealed leukocytosis, severe anemia, low platelet count, abnormal renal function test, deranged liver enzymes with conjugated hyperbilirubinemia, raised international normalized ratio, and hypoalbuminemia. Arterial blood gas showed metabolic acidosis. The raised pancreatic enzymes with radiological evidence of pancreatitis helped establish the diagnosis. Patient’s condition improved with antimalarial, blood transfusion, circulatory support, and hemodialysis. The most possible mechanism of pancreatitis in malaria is microvascular occlusion with resultant ischemia, activation of pancreatic enzymes, and injury to pancreas due to autodigestion. Prognosis was good in our case of malarial pancreatitis. Keywords: Falciparum, infection, malaria, pancreatitis, prognosis, treatment
Introduction Clinical presentation of malaria is variable and may involve various organ systems. Although most infected individuals have relatively benign febrile illness, 1-3 million deaths/ year occur worldwide due to severe malaria. This comprises severe syndromes such as cerebral malaria, severe anemia, jaundice, renal failure, and acute respiratory distress syndrome (ARDS), either alone or in combination. Out of the four species, Plasmodium falciparum has the potentiality of developing all these complications, and most deaths have been ascribed to falciparum malaria. Though different organs have been involved in falciparum malaria, pancreas has not been a common organ involved so far. Hence, pancreatitis is described as a rare complication of P. falciparum malaria.[1,2]
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DOI: 10.4103/0975-2870.186061
associated with vomiting for 3 days. However, as the patient developed altered sensorium on the 4th day, he was shifted to the intensive care unit (ICU). In the ICU, on detailed clinical examination, the patient was found to having a temperature of 102°F, heart rate 120/min, respiratory rate 26/min, Glasgow Coma Scale (GCS) of E2V2M5, agitated, bleeding from mouth, hypotensive with low blood pressure of 90/56 mmHg, icteric, liver enlarged and palpable 5 cm below the costal line, and spleen enlarged by 4 cm, and abdomen distended and tender. Various investigations done in ICU [Table 1] revealed high white blood cell (WBC) of 20,520/cumm; severe anemia with Hb% of 5.0 g/dl; low platelet count of 20,000; worsening renal function test (RFT) with blood urea of 256 mg/dl and serum creatinine of 5.08 mg/dl; liver enzymes serum glutamate pyruvate transaminase 412, serum glutamic oxaloacetic transaminase 642 with conjugated hyperbilirubinemia of 15 mg/dl, international normalized ratio 2.5, and hypoalbuminemia, amylase 962 u/l, and lipase 2183 u/l. Arterial blood gas showed metabolic acidosis [Table 1]. Histidine-rich protein-2 antigen specific to P. falciparum tested positive, This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact:
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Case Report A 26-year-old male from malaria endemic area admitted with chief complaints of high-grade intermittent fever
How to cite this article: Taye MK, Saloi DK, Choudhury B. Acute severe pancreatitis in falciparum malaria. Med J DY Patil Univ 2016;9:512-4.
Address for correspondence: Dr. Mrinal Kanti Taye, Department of Anaesthesiology and Critical Care, Gauhati Medical College and Hospital, Bhangagarh, Guwahati - 781 032, Assam, India. E-mail:
[email protected] 512
© 2016 Medical Journal of Dr. D.Y. Patil University | Published by Wolters Kluwer - Medknow
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Table 1: Investigation reports of malarial pancreatitis patient in intensive care unit Investigation parameters Hb% Hct MCV MCH MCHC RBS TC N L E M Platelet PCV Urea Creatinine Bilirubin Conjugated SGPT SGOT ALP Total protein Albumin Na+ K+ CA++ Mg+ Amylase Lipase RBS 6 am 6 pm INR
1st day 9.4 20.5 79.8 30.4 38.0 Normochromic Normocytic 14,590 72 15 1 11 60,000 20 156 3.8 15 13.8 412 642 182 6.2 2.9 132 5.1
2nd day BPPPP 5.3
3rd day BB 5.9
4th day
5th day (D) B 7.7
20,520
21,750 66 20 0 12
30,590
28,000 72 15 2 8 115,000
256 7.96 10 8.2 152 260 101
300 (d) 8.01
30 190 4.1
3.3
150 4.6 7.1 3.3
154 4.4
147 4.1
142 3.4
142 3.1 6.4 2.1 800 1500
150 160 1.5
132 134
130 150
20,000 18 256 5.08
20 300 6.6
136 5.1
136 4.5
962 2183 203 261
223 192 2.5
132 126
6th day
7th day
156 132
9th day
13,280
1300 2554 120 194
8th day 6.2
162 2.8 7 40 80 89
Gradual improvement of all parameters following treatment. B: Blood transfusion, P: Platelet transfusion, D: Hemodialysis, Hct: Hematocrit, MCH: Mean corpuscular hemoglobin, MCV: Mean corpuscular volume, MCHC: Mean corpuscular hemoglobin concentration, RBS: Red blood cell, TC: Total cholesterol, PCV: Packed cell volume, SGPT: Serum glutamic pyruvic transaminase, SGOT: Serum glutamic oxaloacetic transaminase, ALP: Alkaline phosphatase, INR: International normalized ratio
peripheral blood smear for malarial parasite found to be P. falciparum positive, typhoid negative, hepatitis B surface antigen negative, retroviral test negative, urine c/s no growth, blood c/s no growth, ultrasonography of whole abdomen showed gallbladder wall edematous, mild per portal cuffing with moderate hepatosplenomegaly, computed tomography abdomen showed peripancreatic fluid collection with diffusely enlarged pancreas with low density due to edema [Figure 1]. The patient was resuscitated with intravenous (IV) fluids of 3% NaCl and circulatory support of noradrenaline infusion and with Ryles tube aspiration. Treatment continued with IV artesunate 120 mg stat followed by 120 mg after 6 h and 120 mg once daily for 5 days, clindamycin 600 mg thrice daily, piperacillin-tazobactam 2.25 g thrice daily with renal dose adjustment, pantoprazole once daily, ondansetron thrice daily, and sodium bicarbonate for acidosis. According Medical Journal of Dr. D.Y. Patil University | July-August 2016 | Vol 9 | Issue 4
to investigation reports, patient was infused with 2 units of platelets, 2 units of fresh frozen plasma, and 2 units of packed cell. Patient’s GCS and hemodynamic status improved with antimalarial and blood transfusion so circulatory support was withdrawn. The patient was kept nil per orally for 2 days, but as the patient’s abdominal distension and abdominal pain reduced, he was allowed to resume his normal diet. Patient clinically improved but RFT continued rising with urea 300 and creatinine 8.01. The patient underwent one session of hemodialysis. In spite of deranged RFT, patient’s urine output remained high with maximum of up to 7000 ml. After single hemodialysis, GCS improved to 15/15. Gradually, renal function corrected toward near normal with urea 162 mg/dl and creatinine 2.8 mg/dl and WBC-reduced to 13,280/cumm amylase, lipase 800 u/l, and 1500 u/l, respectively. Patient shifted out of emergency ICU to ward on the 9th day. 513
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in fluid management as patient had to undergo dialysis due to renal failure in spite of pancreatitis a situation where adequate hydration is necessary.
Conclusion Pancreatitis, until now was thought to be a rare association of complicated malaria with multiple organ involvement, is gradually increasing in its incidence as reported from various regions of malaria endemic areas. In patients of malaria with or without abdominal pain, pancreatitis should be suspected if the general condition of the patient deteriorates rapidly. Figure 1: CT scan in acute pancreatitis. CT findings reveal diffusely enlarged pancreas with low density from edema. C: Colon, St: Stomach, P: Pancreas
Discussion Falciparum malaria is known to cause multisystem involvement and results in severe manifestations. However, pancreatitis is a less described complication of falciparum malaria. In 1907, in a review of 105 cases of pancreatitis, the author could not find one patient of pancreatitis caused by falciparum malaria.[3] Complicated falciparum malaria presented either as cerebral malaria or acute renal failure has higher mortality rate. Patient of malaria with various presentations of fever, ARDS, hemolysis, pain in abdomen, vomiting complicated with pancreatitis with or without multiorgan failure has been reported, but whether it is mere association or an actual causative factor is still to be evaluated.[4] It is proposed to verify the most possible mechanism of pancreatitis in malaria is microvascular occlusion with resultant ischemia, activation of pancreatic enzymes, and injury to pancreas due to autodigestion. If autopsy finding of severe falciparum malaria shows hemorrhage in pancreatic parenchyma and there is no evidence of drug toxicity, obstructive cause, or alcohol abuse, it is reasonable to think that pancreatitis was secondary to malaria.[5] Non-falciparum malaria can also cause acute pancreatitis.[6] Other infections such as dengue can cause pancreatitis.[7] There are several common causes of acute pancreatitis, principally excessive alcohol intake and gallstones, and there are many rare causes. Parasitic hookworm infestation is a very rare cause of pancreatitis.[8-10] Infection is among uncommon causes of acute pancreatitis; hence, this case is important to discuss. Acute pancreatitis due to malaria with abdominal pain should be considered in febrile patients in endemic areas. In addition to antimalarial drug, correction of dehydration, electrolyte imbalance, judicious bowel rest, and prophylactic antibiotic should be administered to patients with malarial pancreatitis.[11,12] In our case, utmost care had to be taken 514
Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
References Mohapatra MK, Gupta MP. Falciparum malaria complicated with acute pancreatitis: A report of case series. J Vector Borne Dis 2011;48:177-9. 2. Koram KA, Molyneux ME. When is “malaria” malaria? The different burdens of malaria infection, malaria disease, and malaria-like illnesses. Am J Trop Med Hyg 2007;77 (6 Suppl):1-5. 3. Egdagl A. A review of 105 reported cases of acute pancreatitis, with special reference to aetiology: With report of two cases. Johns Hopkins Med J 1907;18:130-2. 4. Gurman G, Schlaeffer F, Alkan M, Heilig I. Adult respiratory distress syndrome and pancreatitis as complications of falciparum malaria. Crit Care Med 1988;16:205-6. 5. Sarma PS, Kumar RS. Abdominal pain in a patient with falciparum malaria. Postgrad Med J 1998;74:425-7. 6. Sharma V, Sharma A, Aggarwal A, Bhardwaj G, Aggarwal S. Acute pancreatitis in a patient with vivax malaria. JOP 2012;13:215-6. 7. Simadibrata M. Acute pancreatitis in dengue hemorrhagic fever. Acta Med Indones 2012;44:57-61. 8. Shmelev A, Abdo A, Sachdev S, Shah U, Kowdley GC, Cunningham SC. Energetic etiologies of acute pancreatitis: A report of five cases. World J Gastrointest Pathophysiol 2015;6:243-8. 9. Javid G, Zargar S, Shah A, Shoukat A, Iqball A, Gupta A. Etiology and outcome of acute pancreatitis in children in Kashmir (India). An endemic area of hepatobiliary ascariasis. World J Surg 2013;37:1133-40. 10. Tseng LM, Sun CK, Wang TL, Lin AC. Hookworm infestation as unexpected cause of recurrent pancreatitis. Am J Emerg Med 2014;32:1435. 11. Tenner S, Baillie J, DeWitt J, Vege SS; American College of Gastroenterology. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013;108:1400-15. 12. Pasvol G. The treatment of complicated and severe malaria. Br Med Bull 2006;75-76:29-47. 1.
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