Sunil Kumar, Ajit P. Jain , Vikas

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J Vector Borne Dis 47, June 2010, pp. 121–122Falciparum malaria presenting as acute pancreatitisSunil Kumar, Ajit P. Jain & VikasDepartment of Medicine, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha, IndiaKey words Falciparum malaria; pain abdomen; pancreatitisFalciparum malaria is a protozoan disease caused byPlasmodium falciparum transmitted by the bite ofinfected Anopheles mosquitoes. This is a very com-mon disorder in the tropics associated with myriadcomplications. We are presenting here acute pancre-atitis as a sole presentation in a 35-yr old tribal maninfected with falciparum malaria with high para-sitemia. Acute pancreatitis is a well-known compli-cation of falciparum malaria but it was rare becauseit was only presentation even after high parasitemiawithout any other system involvement. Only few re-ports are available regarding this.Case report: A 35-yr old tribal male, labourer byoccupation, presented to the medicine emergencydepartment with a 2-day history of fever which wasassociated with chills, vomiting and generalized ab-dominal pain. There was no significant past medicalhistory of biliary tract disease, lipid disorders, use ofsteroids and pain killers, nor was there a history ofsubstance abuse.On clinical examination at the time of presentation,he was alert, febrile (102°F) with mild jaundice. Hebecame drowsy but arousable two days after admis-sion. His blood pressure was normal. Systemic ex-aminations were within normal limits except epigas-tric tenderness and mild generalised abdominaldistension, with normal bowel sounds. Laboratoryexamination revealed haemoglobin 7.6 g/dL, totalleucocyte count 5800/cmm (with granulocytes68.6%), platelet count 70,000 and haematocrit22.2%. His kidney function tests were normal. In liverfunction tests, serum bilirubin was 4.7 mg/dL, as-partate amino transferase 364 IU/L, alanine aminotransferase 150 IU/L, alkaline phospatase 71 IU/Land serum albumin 2.6 mg/dL with total protein of 6mg/dL. His serum amylase was 472 and serum li-pase 2460 IU/L. A leishman-stained peripheral bloodsmear demonstrated ring-form trophozoites of P.falciparum with high parasitemia (60%). His rapidantigen test for P. falciparum was also positive. Hischest X-ray was normal while abdominal X-rayshowed mild generalised ileus without air-fluid lev-els. Ultrasound abdomen demonstrated anoedematous, enlarged pancreas with minimal fluidin peritoneal cavity (Fig. 1).A diagnosis of severe falciparum malaria with acutepancreatitis was made and treatment was initiatedwith intravenous quinine 1000 mg as loading dose in10% dextrose solution followed by 500 mg in samesolution. He was regularly monitored for hypogly-cemia. In view of high parasitemia and severe anaemiaFig. 1: Ultrasound showing enlarged pancreas with minimalfluid in peritoneal cavity J  VECTOR  BORNE  DIS  47, JUNE 2010 122at presentation, two units of packed red cells wereadministered to the patient. There were marked im-provements in his clinical symptoms. Acute pancre-atitis was managed with analgesics, hydration andsupportive therapy. A ryle’s tube was inserted forbowel rest and antibiotic as ceftrioxone 1 g twice aday was started. His parasitemia were cleared by morethan half after 3rd day of intravenous quinine, hisfever spike came down pain abdomen and jaundicesubsided after 8th day. He was then switched overto oral quinine tab for total duration of one week.He was doing well on follow-up.About two million malaria cases are being reportedevery year by the National Vector Borne DiseaseControl Programme, among them 50% is P.falciparum, the killer parasite. The WHO estimates100 million cases in the Southeast Asia Region, 70%of these occur in India1. It is responsible for majormorbidity and mortality in rural population with vary-ing degrees of presentation. It is said that malariacan present like anything except pregnancy. It is im-portant for the clinicians in tropical countries to bealert for the symptoms and signs which may progressto life-threatening disease of falciparum malaria. Al-though abdominal pain is a frequent symptom inmalaria, in our patient, abdominal pain and vomitingwas related to severe pancreatitis. There are manycauses of abdominal pain in malaria like acalculouscholecystitis, acute surgical abdomen, splenic rup-ture, splenic infarction, and hepatitis/hepatomegaly2.Acute pancreatitis as the sole presentation offalciparum malaria is very rare. At least some of thecurrent major medical text books like Harrison’s textbook of medicine, Davidson, Cecil, and Oxford textbook of medicine does not include P. falciparum asan aetiological agent of pancreatitis. Only few casereports are available regarding this complication offalciparam malaria2–5. Probable mechanism of pan-creatitis in this malaria is capillary blockage byparasitized RBCs and acute haemolysis. Autopsystudies have demonstrated that the small blood ves-sels of the pancreas were packed with parasitizedred cells and rosettes. The parasitized erythrocytesbind to receptors on the endothelial cells by the for-mation of knobs (electron-dense structures) and causeobstruction of capillary blood flow. Jaundice in thispatient is probably due to edema of the head of thepancreas which may have compressed theintrapancreatic portion of the common bile duct. Themost encouraging part is successful outcome of ourpatient.In conclusion, falciparum malaria is very common intropical countries and presents like anything, andacute pancreatitis must be ruled out by doing routineserology like amylase or lipase because of its dread-ful course, hence, mortility. Our case report suggestedthat falciparum malaria should be included in differ-ential diagnosis of acute pancreatitis presenting withfever especially in endemic countries.References1. First meeting of the Regional Technical Advisory Groupon Malaria, Manesar, Haryana, India, 15–17 December2004. New Delhi: World Health Organization, RegionalOffice for South-East Asia. SEA-MAL-239; 1–38.2. Seshadri P, Dev AV, Viggeswarpu S, Sowmya S, PeterJV. Acute pancreatitis and subdural haematoma in a pa-tient with severe falciparum malaria: case report and re-view of literature. Malar J 2008; 7: 97.3. Sarma PS, Kumar RS. Abdominal pain in a patient withfalciparum malaria. Postgrad Med J 1998; 74: 425–7.4. Johnson RC, DeFord JW, Carlton PK. Pancreatitis com-plicating falciparum malaria. Postgrad Med J 1977; 61:181–3.5. Desai DC, Gupta T, Sirsat RA, Shete M. Malarial pan-creatitis: report of two cases and review of the literature.Am J Gastroenterol 2001; 96: 930–2.Corresponding author: Dr Sunil  Kumar, Associate Professor, Dialysis Unit, Department of Medicine, Mahatma GandhiInstitute of Medical Sciences, Sewagram–442 102, India.E-mail: drsunilkr_med@rediffmail.com; sunilkumarmed@gmail.comReceived: 12 February 2010 Accepted in revised form: 21 March 2010

Falciparum malaria presenting as acute pancreatitis

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