A 44-year-old Indian man from north India presented with history of fever of 2 days’ duration with severely painful cold extremities. No pulse could be recorded on examination. A diagnosis of symmetrical peripheral gangrene was made...
Posted July 7,2019 in General Medicine.
Malaria is a protozoan disease transmitted by the bite of infectedAnophelesmosquitoes. It is transmitted in 91 countries containing 3 billion people and causes approximately 1200 deaths each day . Six species of the genusPlasmodiumcause nearly all malarial infections in humans. These arePlasmodium falciparum,Plasmodium vivax, two morphologically identical sympatric species ofPlasmodium ovale,Plasmodium malariae, andPlasmodium knowlesi. The two major human malaria species in India areP. falciparumandP. vivax.
Symmetrical peripheral gangrene (SPG) is characterized by distal ischemic damage in two or more extremities, without large vessel obstruction. This syndrome has been reported in several conditions such as infections, disseminated intravascular coagulation (DIC), and low cardiac output states; it is rarely associated withP. falciparumand mixed malarial infections [3,4].
We report a case of isolatedP. vivaxmalaria presenting with DIC manifesting as SPG. This case is unusual because DIC and SPG have been reported extremely rarely in the literature in association with isolatedP. vivaxmalaria [5,6,7]. Amputations were required in all reported cases to date, however, in the present case, our patient recovered completely with antimalarial and conservative treatment emphasizing the role of early diagnosis and initiation of treatment.
A 44-year-old Indian man, resident of New Delhi, India, a known alcoholic, presented with a 2 day history of fever. His fever was 39.44C (103F), continuous and was associated with chills and rigors. Twodays after onset of fever, he developed painful bluish discoloration of both hands and feet. There was no history of bluish discoloration of tongue, breathlessness, or chest pain. There was no history of hypertension, diabetes, malaria, or any chronic illness in this patient.
A provisional diagnosis of symmetrical arterial ischemia/obstruction with impending gangrene was made and he was investigated further.
His hemoglobin was 15.9g/dL (1318g/dL), hematocrit 44.8% (4050%), total leukocyte count 3.9103/mm3(411103/mm3), and platelet count 8000/mm3(150,000400, 000/mm3). Renal and liver functions were deranged with blood urea 90mg/dL (1545mg/dL), serum creatinine 2.6mg/dL (0.51.5mg/dL), serum bilirubin 12.70mg/dL (0.21.2mg/dL), direct bilirubin 9.86mg/dL (0.00.2mg/dL), indirect bilirubin 2.84mg/dL (0.01.0mg/dL), albumin 2.4g/dL (3.45.0g/dL), aspartate transaminase 116IU/L (540IU/L), alanine transaminase 46IU/L (540IU/L), and alkaline phosphatase 116IU/L (45116IU/L). His prothrombin time was 27.3 (control value 13); his international normalized ratio (INR) was 2.30. His random blood sugar was 64mg/dL and arterial blood gas analysis was unremarkable.
Arterial Doppler of both upper and lower limbs was normal and did not reveal any thrombus in any of the arteries. Radiography of his chest was normal.
He was treated with injection artesunate 120mg followed by lumefantrine 480mg and artemether 80mg two times per day for 3 days followed by primaquine 15mg (0.25mg/kg) per day for 14days; his glucose-6-phosphate dehydrogenase (G6PD) levels were normal. He also received six units of platelet concentrates, along with cautious use of intravenously administered fluids.
The response to this line of treatment was striking and gratifying. He became afebrile by the second day of admission and by the third day all peripheral pulses were well felt along with normalization of blood pressure in all his limbs. Bluish discoloration of both hands and feet started fading by the third day and pain disappeared in the involved regions. His laboratory investigations normalized by sixth day of admission following treatment except for slightly raised bilirubin. He was discharged and no clinical or laboratory abnormality was reported on follow-ups at 2weeks and 6weeks.
P. falciparumcauses the majority of severe and fatal malaria cases and has overshadowed the public health importance ofP. vivaxmalaria.
Complications in severe malaria are either sequestration related, such as cerebral malaria, renal dysfunction, hepatic dysfunction, and acute respiratory distress syndrome (ARDS), or non-sequestration related, such as anemia and thrombocytopenia . Non-sequestration-related complications are known to occur inP. vivaxinfection quite frequently .P. vivaxis less pathogenic thanP. falciparumin otherwise healthy patients, but can cause complicated and severe disease.
SPG is a well-documented but rare clinical syndrome. It is characterized by symmetrical distal ischemic damage leading to gangrene of two or more sites in the absence of large vessel obstruction or vasculitis. DIC is considered to be the final common pathway for the pathogenesis of SPG, irrespective of the etiology. It is proposed to be a cutaneous marker of the same .
DIC is associated with a number of clinical conditions; generally involving activation of systemic inflammation . The common underlying conditions include sepsis, trauma, malignancies, transfusion reactions, acute pancreatitis, obstetric complications, and severe toxic reactions .
Severe malaria has been associated with clinically apparent bleeding or DIC [11,12]. Coagulopathy in severe malaria may result from several pathological processes such as thrombocytopenia, platelet dysfunction, coagulation activation, defects in inhibitors of coagulation, cytokine activation, endothelial cell activation, cytoadherence, and impaired fibrinolysis . SPG caused by malaria is very rare, and most of the cases are associated withP. falciparum.
In a recent study, non-overt DIC was identified in more than 70% of patients of severeP. vivaxmalaria by thromboelastography as well as the conventional coagulation tests . However, there have been very few reports of an association of SPG with isolatedP. vivaxmalaria infection. Aroraet al. reported the index case of malaria with isolatedP. vivaxinfection complicated by SPG involving bilateral hands and feet. Two other cases [6,7] were reported of patients presenting with similar complications later. The management of SPG remains in early identification of the underlying cause and its prompt treatment along with correction of DIC if present. Amputation has been reported in all the cases reported to date. However, in the present case, our patient did not progress to develop dry gangrene and improved with antimalarial and conservative management underlining the importance of early diagnosis and treatment.
Intriguingly all case reports of SPG inP. vivaxhave been from India [5,6,7]. Whether there are genetic factors (host related or pathogen related) or environmental issues at play can be speculated. This would require detailed study and a larger pool of cases. One can also speculate that dehydration, a known risk factor for DIC, delay in seeking treatment, and inappropriate treatment initially by alternative practitioners may also be contributory factors.
The present case highlights SPG as a rare complication ofP. vivaxmalaria. It also emphasizes the need for a high index of suspicion of this clinical entity to differentiate it from conditions such as collagen vascular diseases, thrombotic thrombocytopenic purpura, and other conditions associated with peripheral gangrene. Early recognition and institution of appropriate treatment can prevent progression of gangrene and consequent requirement of amputation.