CASE REPORTS

P. vivax malaria complicated by shock and ARDS

SATHISH KUMAR1, MARK MELZER1, PAUL DODDS1, JULIE WATSON2 &

ROSALYNN ORD2

From the 1Department of Microbiology, King George Hospital, Goodmayes, Essex, UK and 2The Hospital for Tropical

Diseases, Mortimer Market, London, UK

AbstractWe report a case of Plasmodium vivax malaria complicated by shock and ARDS. The patient responded to oral chloroquineand primaquine and PCR was positive for P. vivax DNA and negative for P. falciparum DNA. P. vivax may cause severecomplications and where the possibility of mixed infections exists, blood should be sent for PCR analysis so that mixedinfections can reliably be excluded.

Case report

A 59-y-old Pakastani male, resident in the UK for

34 y, presented with a 4-d history of fever, rigors,

dry cough, myalgia then later diarrhoea and

vomiting. He had travelled to Pakistan, stayed

with his family in Karachi for 2 months and

returned to the UK 4 d earlier. He had no

previous history of malaria and had not taken

antimalarial chemoprophylaxis. On examination he

was febrile, 398C, not anaemic, had no splenome-

galy and was haemodynamically stable. Blood tests

revealed a normal haemoglobin (12.8 g/l), throm-

bocytopenia (39�/109/l), normal renal function

and urine dipstick. Chest X-ray was normal

(Figure 1). A malaria screen was positive for

non-falciparum malaria antigen (Binax ICT) and

a thin blood film revealed P. vivax with a para-

sitaemia of 3%. The patient was started on

chloroquine 600 mg orally, 300 mg 6 h later and

300 mg daily for the next 2 d.

Unexpectedly, on the third d, the patient devel-

oped increasing shortness of breath. Auscultation

revealed bibasal crepitations and O2 saturation on

air fell to less than 80%. Chest X-ray showed

bibasal and right midzone shadowing consistent

with ARDS (Figure 2). The patient was trans-

ferred to the ITU where he required ionotropes for

septic shock and haemofiltration for renal failure.

The blood film was sent to the malaria reference

laboratory, London, which confirmed that all

parasite stages were P. vivax. Subsequently, at

the HTD, London, PCR was performed on

blood from the original blood film and this was

positive for P. vivax DNA and negative for P.

falciparum DNA. A repeat blood film, 2 d after

admission, demonstrated good parasite clearance,

and thus the course of chloroquine was completed

without switching to quinine. His G6PD level was

normal, so oral primaquine, 15 mg orally, once

daily, was commenced for 2 weeks to prevent a

malarial relapse. The patient was discharged from

the ITU after 11 d and from hospital 24 d after

admission.

Potentially fatal complications of falciparum

malaria are well described and these include

cerebral malaria, acute renal failure (ARF) and

adult respiratory distress syndrome (ARDS) [1].

These also occur with P. falciparum and P. vivax

mixed infections but rarely with P. vivax alone. In

the UK, where complications of P. vivax have been

reported [2], one of 2 cases excluded mixed

infection by immunochromatogenic testing but

not by PCR [3], a more sensitive and reliable

assay. In India, a case series reported complica-

tions of P. vivax malaria confirmed by PCR and

Correspondence: M. Melzer, King George Hospital, Barley Lane, Goodmayes, Essex IG3 8YB, UK. E-mail: Mark.Melzer@bhrhospitals.nhs.uk

Scandinavian Journal of Infectious Diseases, 2007; 39: 255�285

(Received 30 June 2006; accepted 6 July 2006)

ISSN 0036-5548 print/ISSN 1651-1980 online # 2007 Taylor & Francis

DOI: 10.1080/00365540600904787

Scan

d J

Infe

ct D

is D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y U

nive

rsity

of

Pitts

burg

h on

07/

10/1

4Fo

r pe

rson

al u

se o

nly.

sequencing of the parasite specific 18S rRNA gene.

In this case series, 2 patients with ARDS and

cerebral malaria died and 9 patients with other

life threatening complications (ARF, ARDS,

ARDS and ARF, and cerebral malaria) survived

[4]. British Infection Society guidelines for P.

vivax malaria recommend outpatient therapy de-

pending on clinical judgement [5]. Although we

concur with this view, clinical judgement is essen-

tial and where appropriate patients should be

admitted to hospital for a period of observation.

Clinicians should be aware that P. vivax malaria

can rarely be associated with potentially fatal

complications even with low levels of parasitaemia.

Where complications occur and there is doubt

regarding the possibility of mixed infection, blood

films should be sent to the Malaria Reference

Laboratory and EDTA blood obtained for PCR

analysis so that mixed infections can be reliably

excluded.

Acknowledgements

We would like to acknowledge P.L. Chiodini, Direc-

tor of the Malarial Reference Laboratory (MRL) at

the London School of Hygiene and Tropical Med-

icine and Consultant Parasitologist at the Hospital

for Tropical Diseases (HTD) for his advice regarding

this case.

References

[1] Tanious MA, Kogelman L, McGovern B, Hassoun PM.

Acute respiratory distress syndrome complicating Plasmo-

dium vivax malaria. Crit Care Med 2001;/29:/665�7.

[2] Lawn SD, Krishna S, Jarvis JN, Joet T, Macallan DC. Case

reports: pernicious complications of benign tertian malaria.

Trans R Soc Trop Med Hyg 2003;/97:/551�3.

[3] Padley D, Moody AH, Chiodini PL, Saldonha J. Ann Trop

Med Parasitol 2003;/97:/131�7.

[4] Kochar DK, Saxena V, Singh N, Kocar SK, Kumar SV, Das

A. Plasmodium vivax malaria. Emerg Infect Dis 2005;/11:/

132�4.

[5] British Infection Society. Algorithm for the initial assessment

and management of malaria in adults. Second draft for

consultation June 2005. www.britishinfectionsociety.org/mala

ria.html

Figure 1. Chest X-ray on admission.Figure 2. Chest X-ray, with onset of ARDS, 4 d later.

256 Case reports

Scan

d J

Infe

ct D

is D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y U

nive

rsity

of

Pitts

burg

h on

07/

10/1

4Fo

r pe

rson

al u

se o

nly.