Acute Pancreatitis-Rare Complication of Falciparum Malaria

Satya Kant Tiwari^1* and Richa Patel^2
*Correspondence: Satya Kant Tiwari, Department of Internal Medicine, All India Institute of Medical Science, New Delhi, India, Email:

Keywords

Acute pancreatitis • Falciparum malaria • Pain abdomen • Fever • Anopheles

Introduction

Falciparum malaria is a very common disorder that is prevalent in the tropics and associated with many complications. Falciparum malaria a protozoan disease is caused by Plasmodium falciparum, transmitted by the bite of infected Anopheles mosquitoes. Acute pancreatitis a rare complication of falciparum malaria which is well documented. It is rare complication because despite having high parasitaemia there is no any other system involvement. A case report of a 26-yr old army man infected with falciparum malaria with high parasitaemia and acute pancreatitis as a sole presentation was presented here. Only few case reports are available.

Case Study

A 26-yr old army man of commandant rank posted in forest belt of Mirzapur district, Uttarpradesh, presented to the medicine emergency department with a 4-day history of high grade fever which was associated with chills and rigor, vomiting and generalized abdominal pain. There was no significant past medical history of lipid disorders, no history of biliary tract disease, no steroids and painkillers intake. There was no history of alcohol intake or any other substance abuse. At the time of presentation on clinical examination, he was febrile (102.2°F) with mild jaundice. His temperature fluctuates over next 2 days, abdominal pain increases and he becomes drowsy. Four days
after admission his condition improved. Blood pressure was normal. Systemic examinations reveals epigastric tenderness with mild generalised abdominal distension with normal bowel sounds. Systemic examinations of other system were within normal limits. Laboratory examination revealed haemoglobin 9.4 g/dL with total leucocyte count 6400/mm3 (with granulocytes 65.6%), platelet count 90,000 MCV 84.5 fl, MCH 30.2 pg and haematocrit 23.1%. Serum bilirubin was 4.2 mg/dL, aspartate aminotransferase 402 IU/L, alanine aminotransferase 202 IU/L, alkaline phosphatase 82 IU/L and serum albumin 2.8 g/dL with total protein of 6 mg/dL. His serum amylase was 502 IU/L and serum lipase 2248 IU/L. His kidney function tests were normal. Peripheral blood smear stained with leishman demonstrated ring-form trophozoites of P. falciparum with high parasitaemia (62%) with rapid antigen test for P. falciparum was also positive. Chest X-ray was normal. Contrast enhanced computed tomography (CECT) scan of the abdomen showing a bulky pancreas with peri-pancreatic fat stranding suggestive of acute pancreatitis (Figure 1). A diagnosis of severe falciparum malaria with acute pancreatitis was made on basis of investigation .Treatment in form of intravenous quinine 1000 mg as loading dose in 10% dextrose solution followed by 500 mg in same solution and was monitored for hypoglycaemia.

A Ryle’s tube was inserted for bowel rest and acute pancreatitis was managed with analgesics, hydration and supportive therapy. Antibiotic ceftriaxone 1 g twice a day was started and marked improvements in his clinical symptoms was noted, parasitaemia load common bile duct. No correlation between the infestation index and the occurrence of pancreatitis has been established. Encouraging results with successful outcome were seen in patients with acute pancreatitis in previous study and in present patient leads to early diagnosis of pancreatitis in P. falciparum positive cases and management in early stage so as to prevent the life threatening complication of acute pancreatitis. Incidence of Acute pancreatitis is much higher than that being reported because of failure to report the patient presenting with acute abdomen in malaria patient. In tropical countries it is of utmost importance to look for signs and symptoms of acute pancreatitis in a patient presenting with pain abdomen in P. falciparum positive cases. were cleared by more than half after 4^th day of therapy, his fever spike came down pain abdomen and jaundice subsided after 8th day. Oral quinine tab was started 8th day up to 15th day. The patient was discharged on 18^th day and his condition was good on further follow up. Although abdominal pain is a frequent symptom in malaria, in this patient, the persistent and worsening abdominal pain was related to severe pancreatitis a rare complications of falciparum malaria. Abdominal pain and vomiting were reported to be more commonly associated with falciparum infections than with vivax [1] .The various causes of abdominal pain in malaria include Acalculus cholecystitis, acute surgical abdomen, splenic rupture, splenic infarction, splenic torsion and hepatitis/hepatomegaly, acute renal failure and algid malaria [2,3]. The presence of abdominal pain if associated with hepatomegaly has higher mortality in malaria. National Vector Borne Disease Control Programme reported about two million malaria cases every year, among them 50% is P. falciparum. The WHO estimates100 million cases in the Southeast Asia Region [4]. Morbidity and mortality in rural population highest with varying degrees of presentation. Only few case reports are available regarding this complication of falciparum malaria [5-8]. Pancreatitis is an unusual cause of abdominal pain in malaria with less than 10 cases reported worldwide. The parasitaemia in three of these patients were low (0.5% to 1.5%). As none of these patients had fulfilled WHO criteria for severe falciparum malaria. There is no acute respiratory distress syndrome either with severe malaria or with acute pancreatitis in this young man. The parasitized erythrocytes bind to receptors on the endothelial cells by the formation of knobs (electron- dense structures) and cause obstruction of capillary blood flow .Capillary blockage by parasitized RBCs and acute haemolysis was pathophysiological mechanisms that result in pancreatitis. Occlusion of blood vessels of the pancreas with parasitized RBCs and rosettes have been demonstrated in several autopsy studies.

Discussion

Jaundice is probably because of oedema of the head of the pancreas which compressed the intrapancreatic portion of the common bile duct. No correlation between the infestation index and the occurrence of pancreatitis has been established. Encouraging results with successful outcome were seen in patients with acute pancreatitis in previous study and in present patient leads to early diagnosis of pancreatitis in P. falciparum positive cases and management in early stage so as to prevent the life threatening complication of acute pancreatitis. Incidence of Acute pancreatitis is much higher than that being reported because of failure to report the patient presenting with acute abdomen in malaria patient. In tropical countries it is of utmost importance to look for signs and symptoms of acute pancreatitis in a patient presenting with pain abdomen in P. falciparum positive cases.

Conclusion

So a conclusion is drawn from this case and earlier cases that as falciparum malaria is common in tropical countries and it can present as pain abdomen with acute pancreatitis so routine serology testing is done to rule out the diagnosis to prevent dreaded complications and to decrease the mortality and mortality

References

1. Beg, MA, N Sani, V Mehraj and W Jafri. “Comparative Features and Outcomes of Malaria at a Tertiary Care Hospital in Karachi, Pakistan.” Int J Infect Dis. 12 (2008): 37-42.
2. Anthoine-Milhomme, Marie-Constance, Chappuy Helene and Cheron Gerard. “Acute Acalculous Cholecystitis in a Child Returning from the Ivory Coast.” Pediatr Emerg Care. 23 (2007): 242-243.
3. Gopisetty, Sunil, Jonahan Sarveswaran, Raj Achuthan and J Davies. “Acute Surgical Abdomen: An Atypical Presentation of Plasmodium vivax Malaria.” Gut. 56 (2007):447-448.
4. “First Meeting of the Regional Technical Advisory Group on Malaria, Manesar, Haryana, India, 15–17 December 2004.” World Health Organization. 2005.
5. Sarma, PS and Kumar RS. “Abdominal Pain in a Patient with Falciparum Malaria.” Postgrad Med J. 74 (1998): 425-427.
6. Desai, DC, Gupta T, Sirsat RA and Shete M. “Malarial Pancreatitis: Report of Two Cases and Review of the Literature.” Am J Gastroenterol. 96 (2001): 930932.
7. Seshadri, Pratibha, Anand Vimal Dev, Surekha Viggeswarpu and Sowmya Sathyendra, et al. “Acute Pancreatitis and Subdural Haematoma in a Patient with Severe Falciparum Malaria: Case Report and Review of Literature.” Malar J. 7 (2008): 97.
8. Johnson, RC, DeFord JW and Carlton PK. “Pancreatitis Complicating Falciparum Malaria.” Postgrad Med J. 61 (1977): 181–183.