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 50-year-old uneducated male of low socioeconomic status was scheduled for amputation of toes. To start with, he had complaint of fever associated with chills and rigors for 3 weeks. He consulted a local practitioner who prescribed some tablets about which patient could not give the details. He noticed blackening of toes of both the feet, which was slow and progressive over 1 week. As he was not responding to the treatment, he was rushed to our medical college. There was no history of trauma, significant drug ingestion particularly ergot, alcohol consumption or smoking. On physical examination, he was febrile, dehydrated, and had pallor; there was no icterus, cyanosis, edema, or significant lymphadenopathy. A pulse rate of 120/min, respiratory rate of 24/min, and blood pressure of 90/70 mmHg was recorded. All peripheral pulses were palpable. On systemic examination, mild hepatosplenomegaly was present and rest of the systemic examination was normal. On local examination, there was blackish discoloration of all toes, extending up to malleoli [Figures and ]. Intavenous line was secured. Ringer lactate was started and investigations were sent for. Reports were as follows [].\nPeripheral blood smear showed ring forms of P. falciparum with occasional gametocytes. Three consecutive blood cultures for bacteria were negative. Color Doppler study of the lower limbs revealed normal flow in both the femorals and the popliteal, with slightly reduced flow in tibial and dorsalis pedis artery with hypoechogenic shadow in its lumen.\nThe patient was given i.v. quinine, loading dose of 20 mg/kg followed by a maintenance dose of 10 mg/kg thrice a day for 2 days. Then, the patient was shifted to oral quinine (dose 10 mg/kg) thrice a day and oral paracetamol 500 mg thrice a day for 5 days. Two units of packed cell transfusion were also given. Fever subsided within 5 days of treatment. His peripheral smear for malarial parasite became negative after 7 days of quinine course. Line of demarcation did not progress any further. For management of gangrene, amputation was planned. All repeated blood investigations were within normal limits except prothrombin time 16.5 s, fibrinogen level 2.9 g/L (normal value 1.5-4 g/L), and D-dimer 1.7. The surgery was done under total i.v. anesthesia.