We present the case of a 17-year-old boy who was admitted to the medical ward of MBGH, RNT Medical College, Udaipur with complaints of fever with chills and rigor for 6 days. Patient noticed blackening of his toes and lower limbs on the third day of fever which was associated with pain and numbness. There was no history of trauma, any drug ingestion, alcohol use, and smoking. Examination revealed pulse 110 beats/min, regular, bounding, with all peripheral pulses felt normally, blood pressure - 100/40 mmHg in right brachial artery, temperature of 101.4°F, respiratory rate - 22 breaths/min. On examination, patient was found to have severe pallor, mild icterus, and blackening of third, fourth, and fifth toe of right foot and fifth toe of left foot with circumferentially patchy area of blackening of bilateral lower legs up to mid-shin [Figures and ]. Overlying skin was dry and wrinkled. Per abdominal examination revealed firm splenomegaly 2 cm below costal margin. Neurological examination revealed decreased sensations over hyper-pigmented area. Cardiovascular system examination revealed a soft functional ejection systolic murmur present at pulmonary area heard all over the precordium. Respiratory system examination was unremarkable. Provisional diagnosis of septicemia with SPG was kept and patient was investigated.\nBlood investigation revealed hemoglobin (Hb) 1.1 g%, total leucocytes count (TLC) 1000 cells/mm3, with 55% polymorphs and 40% lymphocytes, platelets 10,000/mm3 with normocytic normochromic picture on peripheral blood film (PBF) with no immature cells and no parasite was seen. Renal and liver functions tests were normal. Malarial parasite quantitative buffy coat was negative but rapid diagnostic kit for P. falciparum was positive. Anti-nuclear antibody, rheumatoid factor, C-reactive protein, human immunodeficiency virus, hepatitis B surface antigen, anti-hepatitis C virus were negative. Prothrombin time-international normalized ratio (PT-INR) was 18 and 1.41 (control 13). Bleeding time, clotting time were normal. Chest X-ray was normal. Ultrasonography of abdomen revealed gall bladder sludge and mild splenomegaly. Blood culture did not show growth of any pathogenic organism. Color Doppler of both lower limbs showed normal caliber, flow and Doppler indices of bilateral femoral, popliteal, anterior and posterior tibial arteries [].\nDiagnosis of complicated P. falciparum malaria with disseminated intravascular coagulation (DIC) with SPG was kept and patient was treated with injection quinine 600 mg intravenous (IV) 12 hourly slow infusion in 10% Glucose Distilled Water, tablet doxycycline 100 mg twice daily, injection ceftriaxone 1 g IV 12 hourly and with supportive three units of packed cell volume and six units of platelets. After a consultation from cardiothoracic vascular surgeon patient was started on low dose heparin infusion for SPG but patient developed epistaxis soon after starting the infusion, so infusion was stopped and managed conservatively. Patient had an uneventful recovery and discharged from hospital after 10 days. On discharge patient's vitals were normal, Hb - 6 g%, PBF showed normocytic normochromic anemia with occasional macrocytes, TLC - 11,000 cells/mm3, platelets - 1.8 lac/mm3, PT-INR - 15 and 1.19.
A 46-year-old man, previously well, presented at Kapit Hospital, Sarawak, Malaysian Borneo with fever, chills and rigors for 2 days. It was associated with severe epigastric and left hypochondrium pain and loose stool. There was no preceding history of trauma. Upon arrival to the emergency unit, his general condition was stable. Physical examination revealed blood pressure of 123/86 mmHg, pulse rate of 114 beats/min and temperature of 39 °C. His respiratory rate was 23 breath/min and the oxygen saturation on room air measured by pulse oximetry was 97%. The abdomen was generally tender and guarded, maximal at the epigastric region. Bedside focused abdominal ultrasonography revealed free fluid in the abdomen. Chest radiograph did not reveal any obvious sign of pneumoperitoneum.\nHaematological analysis showed haemoglobin of 11.5 g/dL, white blood cell count of 8.2 × 103/μL and platelet count of 77 × 103/μL. His creatinine level was 89 μmol/L and electrolytes were within the normal range. The results of the liver function tests were as follows: aspartate aminotransferase 15 U/L, alanine aminotransferase 11.8 U/L and total bilirubin 22.9 μmol/L. Serum amylase was normal. The arterial blood gas revealed good oxygenation and absence of metabolic disturbance (pH 7.44, PaO2 87 mmHg, PaCO2 34 mmHg, bicarbonate of 22.3 mmol/L and base excess − 1.8 mmol/L). The serum lactate measured was 0.8 mmol/L.\nPlasmodium knowlesi was identified by examination of a Giemsa-stained blood film and the parasitaemia was estimated to be 240 parasites/μL blood. Finger prick blood samples from the patient were spotted on filter paper and sent to the Malaria Research Centre at Universiti Malaysia Sarawak where DNA was extracted as described previously []. The DNA was examined by nested PCR assays specific for P. knowlesi, P. falciparum, P. vivax, P. malariae and P. ovale, which indicated the patient was infected with P. knowlesi [].\nThere was no formal radiological imaging done, such as abdominal ultrasonography or computed tomography, since this service is unavailable at Kapit hospital. Four tablets of artemether–lumefantrine were given upon laboratory diagnosis of P. knowlesi malaria.\nThe patient later developed hypotension despite fluid resuscitation and required single inotropic support, noradrenaline at a dose of 0.2 mcg/kg/min. He simultaneously experienced worsening peritonism. The surgical team was consulted, and he was posted for emergency exploratory laparotomy after stabilization. The anti-malarial was changed to intravenous artesunate in view that the patient was vomiting.\nIntraoperatively, haemoperitoneum was observed upon entering the abdomen, with blood clots seen overlying the splenic region. Gross examination of the spleen revealed tear of splenic capsule and subcapsular haematoma at the superior pole (Fig. ). Otherwise, the spleen was of average size, measuring 12 cm. Total splenectomy was performed and no visceral perforation was seen. The estimated blood loss was 7 L. During the operation, he required high dose of inotrope infusion: noradrenaline up to 2 mcg/kg/min, adrenaline up to 1 mcg/kg/min and dobutamine constant at 5 mcg/kg/min, fluid resuscitation (2 L of crystalloid and 1.5 L of colloid solution) and disseminated intravascular coagulation (DIC) regime transfusion due to massive blood loss. Postoperatively, the patient was managed in the high dependency ward of Kapit Hospital. There, he remained stable, inotrope was weaned off and he was extubated on the next day after the operation. He was administered with intravenous artesunate for 4 days. It was later switched to oral artemether–lumefantrine which he completed following a total of 6 doses. Subsequent blood films were negative for malaria parasites.\nHistopathological examination revealed splenic tissue with focal breaching of the capsule with areas of haemorrhage, consistent with splenic haemorrhage. There were a few brownish pigments within the spleen indicative of malarial pigment. The patient recovered well after the operation and was discharged after 9 days of hospital stay. He was given routine follow up post-malaria treatment and later administered with the routine post-splenectomy vaccinations against Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae. One month later, he was well upon review at the surgical outpatient clinic.