Abstract
Summary
Falciparum malaria is occasionally associated with multiple organ system complications. However, acute pancreatitis rarely occurs as a part of the spectrum. A 13-year-old boy presented with falciparum malaria complicated predominantly by acute pancreatitis. He recovered satisfactorily with supportive measures. To our knowledge, there are less than 10 such documented instances in the literature and they are mostly adults. Acute abdomen in Plasmodium falciparum infection may reveal pancreatitis which should be detected at the earliest.
Introduction
Plasmodium falciparum malaria is a common infection in the tropics and the sub-tropics and is associated with a large number of organ system complications which are potentially fatal. We describe an instance of acute pancreatitis developing during the course of childhood falciparum malarial infection, a complication reported extremely rarely in the existing paediatric literature.
Case history
A 13-year-old, otherwise healthy, boy presented with high-grade fever, jaundice, vomiting and generalized abdominal pain of 7 days’ duration. He was toxic, pale, icteric, irritable and febrile (temperature-103°F). At presentation his respiratory rate was 32/ min, pulse 108/ min and blood pressure 94/70 mmHg. The abdomen was diffusely tender with moderate hepatosplenomegaly. Other systems were normal. On presentation, his blood glucose was 34 mg/dL and was immediately corrected.
Laboratory tests demonstrated the following: haemoglobin 8 g/dL; haematocrit 39%, total leukocyte count 12,500/mm3 (N54, L44, E2), platelets 67,000/mm3, erythrocyte sedimentation rate 32 mm, blood urea nitrogen (BUN) 74 mg/dL, creatinine 4.6 mg/dL, bilirubin 14.5 mg/dL (direct 9.9 mg/dL), alanine aminotransferase 126 IU/L (normal <40 IU/L), asparate aminotransferase 168 IU/L (normal <40 IU/L) and alkaline phosphatase 94 U/L (normal up to 120 U/L). The coagulation screen and electrolytes were normal. A Giemsa-stained peripheral blood smear showed trophozoites of P. falciparum, with quantitative parasitaemia of 20 to 45 parasites per 100 leukocytes. The antigen test (optiMAL) for P. falciparum was positive while that for P. vivax was negative. The Widal test was also negative.
Severe malaria was diagnosed and the patient was started on parenteral artesunate followed by mefloquine and a single dose of primaquine. Cultures of the blood, urine and stools were sterile. He was afebrile within 48 h; however, abdominal pain and vomiting persisted. On the third day, he developed abdominal guarding and rigidity. His serum amylase and lipase levels were 1456 U/L (reference range: 0–200 U/L) and 4562 U/L (reference range: 0–190 U/L), respectively, consistent with the diagnosis of acute pancreatitis. An abdominal contrast computed tomography (CT) scan showed a bulky pancreas with significant peri-pancreatic fat stranding (Figure 1) without evidence of a hollow viscus perforation. A chest radiograph was normal. The serum anti-nuclear antibody, triglycerides, electrolytes and BUN were normal. He was managed with analgesics, intravenous fluids and supportive therapy. He improved remarkably over the next week. He was discharged on the 17th day. His physical examination and abdominal CT was normal at six weeks.
Contrast-enhanced computed tomography scan of the abdomen showing a bulky pancreas with loss of fat planes and non-homogeneous contrast enhancement, suggestive of acute pancreatitis
Discussion
Abdominal pain represents an important manifestation of falciparum malaria. However, acute pancreatitis is rarely implicated as the underlying aetiology. A literature review revealed less than 10 instances of malarial acute pancreatitis and they were mostly in adults. A 26-year-old man who had falciparum malaria complicated acute pancreatitis and right-sided pleural effusion was described by Johnson et al. 1 Other reported complications in falciparum malaria-associated acute pancreatitis include adult respiratory distress syndrome 2 and haemolysis. 3 Desai et al. reported two patients with P. falciparum malaria who developed abdominal pain and vomiting. They were diagnosed with acute pancreatitis, based on biochemical and radiological investigations. 4 A recent report described a 21-year-old man who developed acute pancreatitis and sub-dural haematoma during the course of severe falciparum malaria. 5 The only paediatric report in the literature is provided by Sarma and Kumar in which they describe a 17-year-old boy with falciparum malaria and acute pancreatitis. 6 Sudden, acute haemolysis or capillary blockage by parasite-infected red blood cells has been suggested as probable mechanisms. Clogging and occlusion of pancreatic blood vessels with parasitized red blood cells and rosettes have been demonstrated in autopsy specimens.
Conclusion
Pancreatitis can, at times, be a part of the multiorgan dysfunction syndrome associated with falciparum malaria. Symptoms such as persistent abdominal pain and vomiting in a malarial patient may be a pointer to the development of such a complication. Initial screening with serum amylase and lipase followed by abdominal imaging may lead to the correct diagnosis.