A 28-year-old Sudanese man, with no relevant past medical history, presented to a university hospital, Sudan with a 3-day history of abdominal pain and inability to pass stool and flatus. The pain was colicky in nature and has a severity of 6/10 on a visual analogue scale. On inquiry, the patient documented intermittent fever for 4 days for which he had taken paracetamol tablets (500 mg tab/8 hourly). The fever had irregular spikes without a noticeable rhythm. Besides, he has reported mild myalgia and back pain and sometimes vomiting. The patient has no history of major surgery and not admitted in the previous months to any hospital.\nOn examination, pulse 76 bpm, blood pressure 130/80 mmHg and temp 36.8°C. His abdomen was moderately distended with mild diffuse tenderness with exaggerated bowel sounds. Neither guarding nor rebound tenderness has been documented with tympanic percussion note. Digital rectal examination revealed empty rectum. The rest of the physical examination was unremarkable.\nBlood film for malaria was positive for Plasmodium falciparum (). Complete blood counts revealed a hemoglobin of 13.7 g/dL (11–17 g/dL), white blood cells count of 8400 cells/uL (4.0–11.0 cells/uL) and platelet count of 240 000 cells/uL (150–450 cells/uL). Random blood glucose was normal. Renal function tests were normal with a blood Urea of 42 mg/dL (15–45 mg/dL) and serum creatinine of 1.1 mg/dL (0.6–1.3 mg/dL). Important serum electrolytes were within normal range: sodium (Na+) was 138 mEql/L (135–145 mEql/L), potassium (K+) was 4.2 mEql/L (3.5–5.5 mEql/L), calcium was 10 mg/dl (8.6–10.3 mg/dl) and chloride (Cl−) was 103 mEql/L (96–109 mEql/L). Vidal test for typhoid fever and rapid antibody test was normal. ICT for Hepatitis B, Hepatitis C and HIV was negative. Abdominal X-ray showed distended bowel with gas with no significant air–fluid levels. Abdominal ultrasound revealed loops of distended bowel with mild free intra-abdominal fluid in all four quadrants.\nThe patients were diagnosed with functional bowel obstruction secondary to malaria. The patient was admitted and received nothing per mouth and nasogastric tube for suction of air. He received intravenous Artesunate according to the world health organization (WHO) prescription (2.4 mg/kg at 0, 12 hours, 24 hours then qday). The I.V. artesunate was continued for a total of 3 days from the first dose. The patient administered I.V. fluids in terms of 0.9% normal saline at a rate of 1 litre/8 hourly for 48 hours. He passed flatus about 36 hours after starting the intravenous artesunate and he passed faeces around 48 hours with the resolution of the abdominal pain and distension. A stool examination was performed with no organisms identified. On the fourth day of hospitalization, auscultation showed normal bowel sounds and the patient discharged in good condition on oral artesunate tablets. A blood film has been taken to ensure the clearance of parasites (). The follow-up 1 week later was unremarkable.
A 63-year-old Caucasian woman without medical history stayed for several weeks in Cameroun, without taking any antimalarial chemoprophylaxis. She developed severe gastrointestinal symptoms and, after three days, due to her suspicion of a malaria attack, she took at once four pills of Coartem (each containing 20 mg artemether and 120 mg lumefantrine). After that, the patient became unable to ingest any food or drug and a transfer to Europe was rapidly decided. She became seriously ill during the flight back. On arrival at the airport, she was found stuporous and hypotensive and was rapidly transferred to the intensive care unit (ICU) of the nearest hospital. The diagnosis of Plasmodium falciparum malaria was rapidly made on the blood smear and treatment was started with intravenous quinine and doxycycline (as artesunate was not available). Parasitemia was estimated less than 1%. Admission coagulation tests revealed activated partial thromboplastin time 37 sec, international normalized ratio 1.2, fibrinogen 299 mg/dL, D-dimers >8000 ng/mL (normal, <500), ADAMTS13 activity undetectable (reference range, 50–150%), von Willebrand factor (VWF) antigen 340% (reference range, 50–150%), and platelet count 21,000/mm³. Early complications included refractory hypotension and hypoxemia and neurological worsening. Intubation was required for mechanical ventilation; norepinephrine infusion was progressively increased to the maximal infusion rate of 46 μg/min. An acute left ventricular dysfunction could be demonstrated at echocardiography. Continuous venovenous hemofiltration was initiated for acute renal failure. Due to the evidence of multiple organ failure and despite relatively low parasitemia, exchange transfusion therapy was performed. Only one session of 87 minutes was performed. The patient's theoretical total blood volume was 4407 mL; on the whole, 1409 mL of red blood cells was removed and replaced by 1277 mL of packed red blood cells. Blood coagulation tests remained disturbed, with epistaxis and rectal bleeding. The nadir of platelet count (5,000/mm³) and plasma fibrinogen (66 mg/dL) was noted on day 4, but there was only a mild increase in activated partial thromboplastin time and prothrombin time. The activity of ADAMTS13 slightly increased to 32%; no inhibitor or ADAMTS13 autoantibodies were found. From day 2, blackish discoloration of both hands and feet was noted and by the following days a definite line of demarcation was observed between gangrenous and normal skin (). Ultrasound-Doppler examination confirmed the absence of distal perfusion. Plastic surgeon suggested postponing the extensive surgery. Further clinical course was characterized by repeated candidemia (days 4, 7, 9, 10, and 11) and bacteraemia (Pseudomonas aeruginosa on day 7 and Enterococcus faecalis on days 12, 13, and 18), despite appropriate antifungal and antimicrobial therapy. The abdomen computed tomography (CT) failed to reveal bowel ischemia, but diffuse thickening of the jejunal wall was found. Endoscopy on day 11 disclosed multiple duodenal ulcerations from ischemic origin (); colonoscopy performed on day 28 was also consistent with ischemic injury disseminated in the sigmoid colon (). Norepinephrine infusion had been definitely stopped on day 14. The patient regained consciousness progressively from day 22 and extubation was possible on day 32.\nThe decision to perform quadriamputation was discussed after recovery from the critical period, when she became able to give her consent. Surgery was performed two months after the first signs of peripheral gangrene. Renal function recovered and the patient was further transferred for rehabilitation.