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 54 years old male Ugandan presented to Kenyatta National Hospital, a major referral tertiary hospital, in Kenya. He had initially reported with headache and joint pain to a local health facility in Uganda and was diagnosed to have severe Plasmodium falciparum malaria infection, and thereafter treatment with intravenous quinine commenced.\nTreatment at the facility had been responsive; however two days after the onset, the patient started experiencing episodes of headache, pain, numbness, coldness, and swelling of the extremities. This was followed by darkening of the digits of his toes and hands, which gradually progressed proximally.\nOn presentation at out institution, he was conscious, alert, oriented, but lethargic and unable to walk. He was a non-smoker and non-alcoholic, and had no history of diabetes, hypertension or any angiopathies. He however had a history of numerous episodes of malaria bouts and a family history of hypertension with his father having succumbed to a stroke.\nOn physical examination, apart from fever, abdominal, cardiovascular, respiratory, and neurological systems were normal. Jaundice, pallor and cyanosis were absent. A right low paramedian scar was noted secondary to appendicectomy conducted in the year 1995. On local examination, the overlying skin cold, dry, wrinkled, and was darkened with a clear line of proximal demarcation (). Pain was present in the regions proximal to the discolouration, and absent in the distal regions.\nInvestigations tested negative for HIV, HBV, HCV, and VDRL on ELISA. Urea, Electrolyte and creatinine tests were normal. Clotting profile showed a prolonged Prothrombin time of 19sec, Prothrombin time index of 74%, and an INR of 1.36. A haemogram showed macrocytic normochromic anaemia (Hb 9.03 g/dL, MCV 89.9fL, MCH 29.5pg, MCHC 27.2g/dL), Hct 33.2%, RBC 3.69x1012/L. WBC 4.39x109, Neutrophils 2.11x109 (48.2%), Lymphocytes 1.73x109 (39.5%), Monocytes 0.314x109 (7.16%), Eosinophils 0.193x109 (4.4%), Basophils 0.035x109 (0.796%).\nAn echocardiogram was normal except for type 1 left ventricular dysfunction and mild tricuspid regurgitation. The Dorsalis pedis pulses showed absence of blood flow, and a diagnosis of Symmetrical peripheral gangrene was made. Management was initiated with clopidogrel, Acetylsalicylic Acid, and Atorvastatin, and quad-amputation recommended. Time was allowed for marginalization of the gangrene, which was noted two months later. Meanwhile fresh frozen plasma was regularly administered to counter suspected thrombophilia.\nFollowing satisfactory marginalization of the gangrene, the patient underwent surgical excision of the necrotic tissue. This involved transmetatarsal amputation of both feet and ray amputation of the hands. The wounds healed well thereafter facilitated by vacuum dressing at -7.5mmHg over one month. He was then referred to plastic surgeons for prosthesis.