Case RepoRt Falciparum Malaria with Acute Viral Hepatitis...
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Vol. 114 • September 2017 28 THE ANTISEPTIC CASE REPORT Dr. Mayank Jain, M.D, D.N.B., Post Consultant Gastroenterologist, Choithram Hospital and Research Centre, Indore. Currently at - Gleneagles Global Health City, Chennai - 600 014. Falciparum Malaria with Acute Viral Hepatitis E MAYANK JAIN Specially Contributed to "The Antiseptic" Vol. 114 No. 9 & P : 28 - 28 Keywords : Malaria, Viral Hepatitis E. Case Report A twenty four year old male patient presented with complaints of fever with chills and rigors for 8 days and yellowish discolouration of eyes for 4 days. He had diffuse abdominal pain with distention for last three days and had developed epistaxis a day prior to admission. He also reported nausea, loss of appetite and malaise. On examination, he was alert, conscious but febrile and had a pulse rate of 120per minute. His blood pressure was normal. He had icterus, pallor and tenderness all over the abdomen. His spleen was palpable three cms below the costal margin and ascites was noted. His outside investigations showed evidence of malaria with elevated bilirubin, transaminases and positive widal titres. His investigations at our centre have been tabulated in the table below. Peripheral smear showed plasmodium falciparum with a parasitic index of 100. IgM anti HEV was positive while IgM anti HAV was negative. Blood culture, widal test, urine culture and G6PD levels were normal. He was given intravenous fluids, artesunate, clindamycin and cefotaxim for five days. Nasal packing was done for epistaxis. He was started on oral feeds from the day of admission itself. He received four units of whole blood and six units of platlets during his stay. He improved symptomatically by the fourth day. However, low grade fever persisted for another one week and he was given lumefantrine and ofloxacin. He was discharged after a stay of fourteen days. At 2 months follow up, he is fine and jaundice free. Discussion Recent onset febrile illness with jaundice poses a therapeutic challenge to the clinician. Most patients who present with a short history are considered to be viral hepatitis. However, mixed infection and malarial hepatitis may also present in a similar manner. Both falciparum malaria and viral hepatitis E are endemic in India. Their coexistence in a patient poses great diagnostic dilemma and therapeutic challenge. Ghoshal et al reported a case of similar coinfection in a twenty year old young girl who finally succumbed to her disease 1 .We did not get an HEV RNA testing as nearly 25% patients lack HEV RNA and viremia is transient 2,3 . The present case highlights a rare presentation of viral hepatitis with malaria. Table1- Investigations parameter Outside investigations 18/10/12 19/10/12 21/10/12 22/10/12 24/10/12 Hb in gm% 9 9.2 7.6 8.4 8.5 Platlets - 20000 80000 90000 110000 Serum bilirubin (mg%) 30.2 34.37 - - 21.5 Direct bilirubin (mg%) - 26.75 - - 16 SGOT/SGPT 1080/2080 180/480 - - - PT/INR - 1.55 - 1.0 1.3 Widal titres 1:320 1:80 - - - Serum Creatinine (mg%) - 1.72 - 1.23 - Peripheral smear Malarial parasite+ P.falciparum + - - - Blood cultures - No growth - No growth - REFERENCES 1. UC Ghoshal, Sanjay Somani, Kamal Chettri, Parvez Akhtar, Rakesh Aggarwal, SR Naik.Plasmodium falciparum and hepatitis E virus coinfection in fulminant hepatic failure. Indian J Gastroenterol.2001;20:111 2. Aggarwal R,Kravezysneski K. Hepatits E-An overview and recent advances in clinical and laboratory research.J Gastroenterol Hepatol.2000;15:9-20 3. Aggarwal R, KiniD, Naik SR, Sofat S, Kravezysneski K. Durationof viremia and fecal viral excretion in acute hepatitis E. Lancet.2000;356:1081-2
Transcript of Case RepoRt Falciparum Malaria with Acute Viral Hepatitis...
Vol. 114 • September 201728 THE ANTISEPTIC
Case RepoRt
Dr. Mayank Jain, M.D, D.N.B.,Post Consultant Gastroenterologist,Choithram Hospital and Research Centre, Indore.Currently at - Gleneagles Global Health City, Chennai - 600 014.
Falciparum Malaria with Acute Viral Hepatitis EMayank Jain
Specially Contributed to "The Antiseptic" Vol. 114 No. 9 & P : 28 - 28
Keywords : Malaria, Viral Hepatitis E.
Case Report
A twenty four year old male patient presented with complaints of fever with chills and rigors for 8 days and yellowish discolouration of eyes for 4 days. He had diffuse abdominal pain with distention for last three days and had developed epistaxis a day prior to admission. He also reported nausea, loss of appetite and malaise. On examination, he was alert, conscious but febrile and had a pulse rate of 120per minute. His blood pressure was normal. He had icterus, pallor and tenderness all over the abdomen. His spleen was palpable three cms below the costal margin and ascites was noted. His outside investigations showed evidence of malaria with elevated bilirubin, transaminases and positive widal titres. His
investigations at our centre have been tabulated in the table below.
Peripheral smear showed plasmodium falciparum with a parasitic index of 100. IgM anti HEV was positive while IgM anti HAV was negative. Blood culture, widal test, urine culture and G6PD levels were normal.
He was given intravenous fluids, artesunate, clindamycin and cefotaxim for five days. Nasal packing was done for epistaxis. He was started on oral feeds from the day of admission itself. He received four units of whole blood and six units of platlets during his stay. He improved symptomatically by the fourth day. However, low grade fever persisted for another one week and he was given lumefantrine and ofloxacin. He was discharged after a stay of fourteen days. At 2 months follow up, he is fine and jaundice free.
Discussion
Recent onset febrile illness with jaundice poses a therapeutic challenge to the clinician. Most patients who present with a short history are considered to be viral hepatitis. However, mixed infection and malarial hepatitis may also present in a similar manner.
Both falciparum malaria and viral hepatitis E are endemic in India. Their coexistence in a patient poses great diagnostic dilemma and therapeutic challenge. Ghoshal et al reported a case of similar coinfection in a twenty year old young girl who finally succumbed to her disease1.We did not get an HEV RNA testing as nearly 25% patients lack HEV RNA and viremia is transient2,3.
The present case highlights a rare presentation of viral hepatitis with malaria.
table1- Investigations
parameter Outside investigations 18/10/12
19/10/12 21/10/12 22/10/12 24/10/12
Hb in gm% 9 9.2 7.6 8.4 8.5Platlets - 20000 80000 90000 110000Serum bilirubin (mg%) 30.2 34.37 - - 21.5Direct bilirubin (mg%) - 26.75 - - 16SGOT/SGPT 1080/2080 180/480 - - -PT/INR - 1.55 - 1.0 1.3Widal titres 1:320 1:80 - - -Serum Creatinine (mg%) - 1.72 - 1.23 -Peripheral smear Malarial parasite+ P.falciparum + - - -Blood cultures - No growth - No growth -
RefeRenCes1. UC Ghoshal, Sanjay Somani, Kamal Chettri, Parvez Akhtar, Rakesh Aggarwal, SR Naik.Plasmodium falciparum
and hepatitis E virus coinfection in fulminant hepatic failure. Indian J Gastroenterol.2001;20:111
2. Aggarwal R,Kravezysneski K. Hepatits E-An overview and recent advances in clinical and laboratory research.J Gastroenterol Hepatol.2000;15:9-20
3. Aggarwal R, KiniD, Naik SR, Sofat S, Kravezysneski K. Durationof viremia and fecal viral excretion
in acute hepatitis E. Lancet.2000;356:1081-2
