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Vol. 114 • October 2017 26 THE ANTISEPTIC CASE REPORT Malarial pancreatitis - a case report MAYANK JAIN Mayank Jain M.D, D.N.B, Consultant Gastroenterologist, Department of Gastroenterology, Choithram Hospital and Research Centre, Indore-17. Madhya Pradesh, India. Introduction About two million cases of malaria are reported every year around the world and Plasmodium falciparum accounts for 50% of these cases.The WHO estimates 100 million cases in the Southeast Asia Region, of which 70% occur in India.This infection is responsible for major morbidity and mortality in our setting. 1 It is said that presentation of malaria can mimic anything except pregnancy. We report an unusual complication of malaria. Case report A 32 year old male patient presented with history of high grade intermittent fever for 15 days, yellowish discolouration of eyes and urine for 7 days and reduced urine output for 3 days. The patient used to consume alcohol daily for last ten years but his last drink was one month back. On examination, he was pale, dehydrated, icteric, had tachycardia and normal blood pressure. Asterixis were noted and hepatosplenomegaly were present. Table 1 shows his blood parameters on admission and day 5 and 8. Peripheral smear and antigen test were positive for plasmodium falciparum infection ABSTRACT A 32 year old male patient presented with history of high grade intermittent fever for 15 days, yellowish discolouration of eyes and urine for 7 days and reduced urine output for 3 days. On investigations, he was found to have plasmodium falciparum infection, which got complicated with development of acute pancreatitis during his stay in the hospital. The patient recovered completely with antimalarials, intravenous fluids and symptomatic care. Specially Contributed to "The Antiseptic" Vol. 114 No. 10 & P : 26 - 27 with a parasitic index of 20. Serological tests for hepatitis B and C virus and HIV were negative. Ultrasound abdomen showed hepatosplenomegaly with fatty changes in the liver.He was given fluids, artesunate, clarithromycin, folic acid and blood transfusion. He showed symptomatic improvement. However on fifth day, he developed sudden onset, severe, epigastric pain with breathlessness. Serum amylase and lipase levels were done and were found to be elevated more than five times. Serum calcium, serum triglycerides and blood sugar levels were within normal limits.Computed tomography scan (figure1) of abdomen showed peripancreatic edema and fat stranding in tail region. The patient was kept nil by mouth, given oxygen and analgesics. The pain reduced over next 48 hours. He was started on oral diet and improved significantly within one week. He was discharged on day 14 and is doing well on followup. Discussion Abdominal pain is not an uncommon occurrence in Falciparum malaria. In a series of 348 malaria patients, Mahmood et al. 2 found abdominal pain in 23 (21.29%) patients. It can be attributed to varied causes like acalculous cholecystitis, splenic rupture,splenic infarction, splenic torsion, hepatitis and hepatomegaly. 3-8 A single case of pancreatitis was found to be caused due to falciparum malaria in a series of 105 patients. 9 Sheshadri et al. 10 have reported a case of acute pancreatitis with subdural hematoma in a patient with falciparum malaria. Acute pancreatitis as a sole complication of falciparum malaria without any other systemic involvement has also been reported from India. 11,12 Very high bilirubin in this patient was probably due to hemolysis and ischemia of the liver due to microvascular occlusion by the parasitized RBCs. Plasmodium falciparum causes accumulation of parasitized erythrocytes causing thrombosis and infarcts in the small vessels of spleen, liver, bone marrow and brain. Less commonly affected organs include small intestine, pancreas, heart and lungs. Mechanism proposed for pancreatitis in malaria is ischaemia of pancreas from microvascular occlusion and another is because of acute hemolysis. The parasitized erythrocytes bind to receptors on the endothelial cells by the formation of knobs (electron-dense structures) and cause obstruction of capillary blood flow . Autopsy studies have demonstrated occlusion of blood vessels of pancreas with parasitized red blood cells (RBC) and rosettes. Though the reported patient
