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.
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.