Unusual presentation of acute pancreatitis in falciparum malaria
The present case report is about a 40-year-old male patient who presented with high-grade fever associated with chills, jaundice vomiting and abdominal pain for 4 days. There was no history of cough, burning micturition, diarrhea or altered sensorium. On physical examination, he was alert, but febrile (103° Fahrenheit) with mild jaundice. He gradually became drowsy 3 days after admission. Systemic examinations were within the normal limit except epigastric tenderness and abdominal distension with normal bowel sounds. Laboratory investigations revealed hemoglobin - 10.2 g/dl, total leucocyte count - 15,100 (with Neutrophil - 87%) and platelets - 2.75 lacs/cu.mm. Peripheral blood smear revealed ring forms of P. falciparum. Immunochromatographic test for P. falciparum histidine-rich protein 2-based assay was strongly positive. Liver function testing showed serum Total Bilirubin - 4.4 mg/dl (Direct Bilirubin - 2 mg/dl) and serum aminotransferases and alkaline phosphatase were within normal limits. Serum amylase was 525 IU/L and serum lipase was 250 IU/L. Renal function and electrolytes were normal (Serum urea - 32 mg/dl, serum creatinine - 1.2 mg/dl, serum sodium - 140 meq/L and serum potassium - 4.1 meq/L). Urine and blood cultures came out to be sterile. Serum calcium was 9.2 mg/dl and fasting lipid profile was within the normal limits (cholesterol - 170 mg/dl, triglycerides - 103 mg/dl, high density lipoprotein - 36 mg/dl, low density lipoprotein - 114 mg/dl and very low density lipoprotein-20 mg/dl). Chest X-ray was normal and abdominal X-ray showed “Ileus” without air-fluid levels. Ultra sonography abdomen demonstrated an edematous, enlarged pancreas with minimal fluid in the peritoneal cavity. Computed tomography (CT) scan of the abdomen revealed edematous, enlarged pancreas with multiple fluid collections around pancreas and in the peritoneal cavity []. A diagnosis of severe falciparum malaria with acute pancreatitis (Grade E, CT severity index-4) was made and treatment was initiated with intravenous artesunate. There was marked improvement in his clinical symptoms in next 48 h. Acute pancreatitis was managed with analgesics, hydration and supportive therapy. Ryle's tube was initially instituted for bowel rest. After 3 days, his spikes of fever came down. From day 5, he started tolerating oral feeds. His pain abdomen and jaundice subsided after 8 days. He was discharged after a hospital stay of 12 days. On his follow-up visit, 2 months later, he was symptom free and doing well.