Peripheral gangrene in patients with severe falciparum malaria: report of 3 cases

Acute Peripheral and/or Cutaneous Ischemic Syndrome: What Rheumatologists Should Know

ABSTRACT

In daily practice, the frequent appearance of limb and/or skin necrosis, which we term "acute peripheral and/or cutaneous ischemic syndrome" (APCIS), can be a manifestation of numerous underlying diseases, or it can sometimes be a clinical phenomenon whose etiology is undefined even after a wide investigation. The mechanisms for the development of APCIS include vessel wall abnormalities (atherosclerosis, vasculitis, and calciphylaxis), embolic processes (infectious endocarditis, atrial myxoma, and cholesterol emboli), local thrombotic injuries (genetic or acquired thrombophilias and heparin- and warfarin-induced ischemia), dysproteinemias (cryoglobulinemia and cryofibrinogenemia), or venous limb gangrene. Here, we report 5 illustrative cases of APCIS with different pathogenetic mechanisms, thereby highlighting some clinical conditions that cause APCIS that may be of special interest for rheumatologists, such as antiphospholipid syndrome, primary and secondary vasculitis, and cryoproteinemias. Furthermore, we describe a large spectrum of other causes of APCIS beyond the scope of rheumatology. Because there are no validated guidelines for APCIS, we tentatively propose an initial diagnostic workup and a therapeutic approach based on full-dose anticoagulation and immunosuppressive therapy.

Disseminated intravascular coagulation presenting as symmetrical peripheral gangrene: a case report

Introduction

Plasmodium vivax was traditionally thought to be benign; however, nowadays it presents with a myriad of systemic complications like cerebral malaria, acute respiratory distress syndrome, acute kidney injury, acute pancreatitis, hepatic dysfunction, and disseminated intravascular coagulation, which were earlier attributed only to Plasmodium falciparum malaria. Here we report a case of a middle-aged man who presented with disseminated intravascular coagulation manifesting as symmetrical peripheral gangrene. What makes this case more interesting is that the malaria isolated was Plasmodium vivax instead of Plasmodium falciparum. Such findings were previously reported, but this is the first case where the patient was managed conservatively with antimalarial drugs without the need for amputation, which focuses on the very important role of early diagnosis and timely management.

Case presentation

A 44-year-old Indian man from north India presented with history of fever of 2 days’ duration with severely painful cold extremities. No pulse could be recorded on examination. A diagnosis of symmetrical peripheral gangrene was made. During the etiological evaluation, Plasmodium vivax malaria was found leading to disseminated intravascular coagulation causing this complication. He was started on artesunate and lumefantrine combination therapy and he recovered completely without the requirement of amputation.

Conclusion

This case highlights the non-benign nature of Plasmodium vivax and its emerging complications. Also it correlates symmetrical peripheral gangrene with Plasmodium vivax malaria. It also emphasizes the importance of timely diagnosis and intervention to reduce mortality and morbidity.

Plasmodium falciparum Malaria Complicated by Symmetrical Peripheral Gangrene, Bowel Ischemia, Repeated Candidemia, and Bacteraemia

A 63-year-old Caucasian woman developed severe Plasmodium falciparum malaria when travelling back from Cameroun. No antimalarial chemoprophylaxis had been observed. The patient was immediately admitted to the intensive care unit after evidence of multiple organ failure (coma, shock, acute respiratory distress syndrome, acute renal failure, etc.). However, initial parasitemia was less than 1%. The patient was managed by intravenous quinine and norepinephrine infusion due to refractory shock. The patient developed as an early complication ischemic lesions of both arms and feet. In addition to laboratory changes consistent with disseminated intravascular coagulation, there was also evidence for a low activity of the von Willebrand factor (VWF) cleaving protease ADAMTS13. Later complications included repeated candidemia and bacteraemia despite appropriate therapy; the origin appeared to be diffuse ischemic injury of the gastrointestinal tract. The patient ultimately recovered, but quadriamputation was necessary to treat symmetrical peripheral gangrene (SPG). In severe Plasmodium falciparum malaria, ischemic changes may be due to microvascular obstruction, but, in patients with low parasitemia, other endothelial factors may also be involved as observed in other groups of thrombotic microangiopathies.

Peripheral gangrene in an 18-month-old boy with Plasmodium vivax malaria

An 18-month-old boy presented with a high-grade fever, generalised petechiae and rapidly progressive, blackish discolouration of the fingers of the hands for the past 3 days. At presentation, he was haemodynamically stable. There were gangrenous changes in the index and middle fingers of both hands. Plasmodium vivax was demonstrated in the peripheral blood smear but there was no evidence of disseminated intravascular coagulopathy. The platelet count fell to 10×10(9)/L. Bone marrow aspiration to rule out leukaemia demonstrated schizonts of P. vivax with some atypical lymphocytes. The fingers recovered completely. As far as we are aware, this is the first report of peripheral gangrene associated with P. vivax malaria.

Malaria complicated by gangrene: a case presentation and review

Symmetrical peripheral gangrene (SPG) is an extremely rare complication of malaria. It occurs acutely and progresses rapidly to cause irreversible necrosis of tissue following which debridement or amputation is inevitable. We present a case of malaria complicated by SPG. A 54-year old male developed SPG two days after he was diagnosed with severe malaria and treated with intravenous quinine. Despite intervention quad-amputation was necessary as the gangrene had involved all four limbs. SPG secondary to malaria is caused by obstruction of arterioles following sequestration of parasite infected erythrocytes. This is extremely rare, hence almost never anticipated during management of malaria patients. Furthermore due to its rapid progression, it is almost always detected at an advanced irreversible stage. Physicians managing malaria should therefore be vigilant, and look out for SPG, as its prognosis is dependent on correct and timely intervention.