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 29-year-old male peacekeeper, deployed in the Democratic Republic of Congo (DRC) for 2 months, presented with a history of 3-day fever, headache, fatigue and 1-day jaundice. There was no past medical history. He was taking compound dihydroartemisinin tablets (dihydroartemisinin + piperaquine phosphate + trimethoprim) weekly as chemoprophylaxis since entering the mission area. Physical examination showed fever (39.4 °C), acute sick looking, poor spirit, yellow staining of skin and sclera.\nPulse oxygen saturation was 96%. Glasgow coma scale (GCS) was 15. Ultrasonic examination of the abdomen showed splenomegaly. The blood smear revealed 8% parasitemia. The laboratory results after admission were summarized in . Of note were hyperbilirubinemia (total bilirubin 81.3 µmol/L), electrolyte disturbance, and thrombocytopenia. Hepatitis series tests were negative. A rapid diagnostic test was positive for Plasmodium falciparum. A diagnosis of severe falciparum malaria was made.\nWe carried out antimalaria therapy with intramuscular artemether 240 mg at admission and 160 mg at 12, 24 h later (artesunate was temporarily unavailable), correcting dehydration and the electrolyte disturbance, and protecting liver function. The patient did not sweat and the body temperature did not drop after antimalarial treatment. It was above 39.0 °C. Thirty-six hours after admission, he felt left upper quadrant pain, combined by nausea, vomiting, and diarrhea, all of which occurred for three times. The pain was so severe that he could not take a deep breath or cough, resulting in shallow and fast breathing, and a pulse oxygen saturation of 92%. And this was followed with progressive abdominal distension and an inability to pass stool and flatus. On examination, the patient was extremely weak and tired. Without abdominal guarding and rigidity, tenderness was obvious in the left. There was no rebound tenderness. Bowel sounds disappeared. In addition, the blood smear revealed 5% parasitemia. Liver function deteriorated (total bilirubin 189.5 µmol/L), and platelets decreased further (52 × 109/L). Fifty-five hours after admission, his abdominal pain was significantly worse. The consciousness was gradually indifferent, and GCS was 13. Breath rate was 45/min, and pulse oxygen saturation was 89%. X-ray of the chest showed lung texture thickening and upright abdominal plain film indicating that the colon was dilated and gas accumulation in the splenic flexure (). Ultrasound of the abdomen showed hepatomegaly and splenomegaly. So we considered the patient was complicated by ACPO. At this time artesunate was available and 2.4 mg/kg body weight administered intravenously (time = 0), then at 12 h and 24 h. At the same time, fasting, no retention enema, rectal decompression tubes and oral 30 mL paraffin oil were taken. One day after these measures, he passed a small quantity of feces; and abdominal pain and distension were relieved. Body temperature also gradually decreased. Blood test showed bilirubin level dropped than before (total bilirubin 165.7 µmol/L), platelets level rose to a certain extent (81 × 109/L), and the blood smear revealed 1% parasitemia. X-ray of the abdomen revealed that dilation of the left colon disappeared, and intestinal gas accumulation decreased (). Five days after admission, the patient could tolerate oral therapy, so he completed a treatment of 3-day artemisinin-based combination therapies.\nWe concluded that ACPO was secondary to malaria. Ten days later, all symptoms disappeared and the patient was discharged. His 1-month follow-up was unremarkable.