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.
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.