World Rural Health Conference
Home Print this page Email this page Small font size Default font size Increase font size
Users Online: 236
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents 
CASE REPORT
Year : 2016  |  Volume : 5  |  Issue : 3  |  Page : 691-694  

Acute pancreatitis due to malaria: A case report of five patients and review of literature


Department of General Medicine, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication30-Dec-2016

Correspondence Address:
Kundavaram Paul Prabhakar Abhilash
Department of General Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4863.197302

Rights and Permissions
  Abstract 

Malaria is endemic in large parts of India and can cause multiorgan failure and death. Acute pancreatitis as a complication is rare and is potentially fatal. This case series describes five adult patients between 2005 and 2010 who presented with a short duration febrile illness and diagnosed to have malaria with acute pancreatitis. The mean age of the five patients with acute pancreatitis was 40.4 years and four of them were males. None of them were alcohol consumers and did not have any other risk factor for acute pancreatitis. Plasmodium falciparum was responsible for all the cases. Pancreatic enzymes were significantly elevated in all the patients with a mean serum lipase level of 1795 U/L (normal value: <190 U/L) and a mean serum amylase level of 584 U/L (normal value: <100 U/L). Ultrasonography evidence of acute pancreatitis (bulky pancreas) was seen in two patients, and a further two patients had minimal left-sided pleural effusion. Thrombocytopenia (platelet count <100,000/cumm), renal dysfunction (serum creatinine >1.4 mg/dl), and hyperbilirubinemia were seen in all the patients. One patient died due to multiorgan failure. Acute pancreatitis is a very rare complication of malaria, and a high index of suspicion is required in patients presenting with severe malaria and abdominal pain.

Keywords: Complication, malaria, pancreatitis


How to cite this article:
Abhilash KP, Ahmed AS, Sathyendra S, Abraham OC. Acute pancreatitis due to malaria: A case report of five patients and review of literature. J Family Med Prim Care 2016;5:691-4

How to cite this URL:
Abhilash KP, Ahmed AS, Sathyendra S, Abraham OC. Acute pancreatitis due to malaria: A case report of five patients and review of literature. J Family Med Prim Care [serial online] 2016 [cited 2018 Dec 19];5:691-4. Available from: http://www.jfmpc.com/text.asp?2016/5/3/691/197302


  Introduction Top


Malaria is a common protozoan disease in tropical countries caused by the genus Plasmodium transmitted by the bite of infected anopheles mosquitoes. Severe complicated malaria is most frequently caused by Plasmodium falciparum and much less commonly by Plasmodium vivax or other Plasmodium species. Abdominal pain as a presenting complaint has been reported in 21.4-33.5% of patients with malaria and is usually mild and transient. [1] It occasionally can be severe and persistent, especially with complications such as splenic infarction, splenic rupture, splenic torsion, acalculous cholecystitis, and hepatitis. However, acute pancreatitis causing abdominal pain and complicating malaria is very rare and there are only 12 cases reported from literature till now. We describe five patients who were diagnosed to have malaria complicated by acute pancreatitis.


  Case Report Top


Five patients admitted in the Christian Medical College, Vellore between 2005 and 2010 with a diagnosis of malaria and acute pancreatitis are described. Malaria was confirmed by demonstration of the characteristic ring forms of either P. falciparum or P. vivax on a thin blood smear. Acute pancreatitis was diagnosed in the presence of at least two of the following criteria: Acute, persistent, and severe abdominal pain not subsiding with proton pump inhibitors, elevation in serum lipase or amylase to three times greater than the upper limit of normal, and characteristic findings of acute pancreatitis on radiographic imaging. Other causes of pancreatitis such as alcohol, gall stones, and hypercalcemia were ruled out.

In addition, a Medline search was performed to identify the cases of malaria with acute pancreatitis reported in the literature using the search terms "malaria," "P. falciparum," "P. vivax", and "pancreatitis." Cases were accepted where information regarding the demographics, laboratory tests, and the outcome was provided.

This study was approved by the Institutional Review Board of Christian Medical College, Vellore (IRB Min No. 8327), and patient confidentiality was maintained using unique identifiers.


  Results Top


The mean age of the patients was 40.4 years, and 4 out of 5 were males. All the patients were healthy before the current illness, and none had prior history of chronic alcohol consumption or cholelithiasis. None of the patients had any prior history of abdominal procedures including endoscopic retrograde cholangiopancreatography. The mean duration of fever before presentation was 7.8 days. All the patients had a history of abdominal pain, which was central and did not improve with proton-pump inhibitors. The pain started 2-9 days after the onset of fever. None of the patients had pain radiating to the back. All of these patients had P. falciparum infection with a variable parasitic index, ranging from 0.14 to 32, as demonstrated on a thin film.

Pancreatic enzymes were significantly elevated in all, with a mean serum lipase level of 1795 U/L (normal value: <190 U/L) and a mean serum amylase level of 584 U/L (normal value: <100 U/L). Ultrasonography evidence of acute pancreatitis (bulky pancreas) was seen in two patients, and a further two patients had minimal left-sided pleural effusion. Thrombocytopenia (platelet count <100,000/cumm), renal dysfunction (serum creatinine >1.4 mg/dl) and hyperbilirubinemia were seen in all the patients.

All the patients were treated with an artemisinin-based combination therapy along with doxycycline. Acute pancreatitis was managed conservatively with nil oral intake and opioid pain killers. Gradual feeds were started once the pain reduced. One of the patients (Case 5) required a nasojejunal tube placement for pancreatitis. Clinical characteristics and medications including antibiotics are mentioned in [Table 1]. Four of the patients required hemodialysis for renal dysfunction. One patient (Case 3) who presented with a parasitic index of 0.5% severe malaria with hepatic, renal, neurological and hematological dysfunction and required invasive ventilator support and multiple sessions of hemodialysis. Despite these aggressive measures, he succumbed to the illness on the 7 th day of admission. The patient profile, laboratory investigations, and outcome of these five patients are shown in [Table 2].
Table 1: Clinical characteristics and medications


Click here to view
Table 2: Profile of five cases of malaria with acute pancreatitis


Click here to view



  Discussion Top


India's expansive geography and tropical environment are ideal for sustaining malaria vectors, and it accounts for 76% of cases from Southeast Asia. Although the overall deaths have reduced since the launch of National Malaria Control Program, it is argued that reports of approximately 1000 deaths per year are grossly underestimated. [2] Multiorgan involvement or dysfunction is reported in both P. falciparum and P. vivax infections. P. falciparum contributes to 52% of the total malaria cases in India and is responsible for the majority of deaths. [2] Acute pancreatitis as a complication of malarial infection, though rare, has been usually reported with P. falciparum. It has been associated with at least four deaths, in the reported 15 cases reported in literature based on our Medline search. Primary care physicians deal mostly with vivax malaria in most parts of India as it is usually the predominant species. In our case series, two patients had pancreatitis due to P. vivax malaria. Recent studies have shown that vivax malaria can be as severe as falciparum malaria, a fact consistent with our finding of a severe complications such as pancreatitis due to P. vivax. [3]

In our case series, one patient died as a result of multiorgan involvement including acute pancreatitis, the causative organism being P. falciparum. Only two patients (Case 1 and Case 4) had a high parasitic index. Seshadri et al., Mandal et al. and Mohapatra and Gupta have reported pancreatitis with very high parasitic indices. [4],[5],[6] Hyperparasitemia though a predictor for severe malaria is not the only marker for severity. In patients not previously exposed to malaria poor immunity may result in severe disease even with parasitic index as low as 2%. The pathogenesis of pancreatitis is probably not different from that of other organ involvement in malaria and includes cytoadherence of infected red blood cells (RBCs) to the vascular endothelium, sequestration of RBCs, and rosetting. This is especially true in falciparum
malaria. However, sequestration occurring in other organs including pancreas is not known as of now.

In our literature search, we found only 15 cases of malaria complicated by pancreatitis and their profile is summarized in [Table 3]. [4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15]
Table 3: Literature review of patients with malaria and acute pancreatitis


Click here to view


In our country, malaria continues to be a major public health problem in India, accounting for sizeable morbidity and mortality. The burden of falciparum malaria is very high in places such as Orissa and the Northeastern states where the mortality rate due to malaria is even higher. Fever and abdominal pains are very common presentations to the emergency department and pancreatitis accounts for about 11% of those cases. [16] Primary care physicians' deal with these common problems in their daily practice and their etiology quite often remains a diagnostic dilemma. Greater awareness of the rare complications of a common infection such as malaria is essential to recognize it early and to initiate early management or early referral to a higher center.


  Conclusion Top


Physicians may be familiar with the various complications of falciparum malaria but less so with acute pancreatitis. The ability to properly diagnose and to manage acute pancreatitis due to malaria is particularly important in malaria-endemic areas such as India. Maintaining a high index of suspicion for acute pancreatitis in patients with malaria presenting with abdominal pain can be important in the early diagnosis and prevention of pancreatic complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Zaki SA. Abdominal pain as a presenting feature in malaria. Sri Lanka J Child Health 2010;39:158-9.  Back to cited text no. 1
    
2.
Kumar A, Valecha N, Jain T, Dash AP. Burden of malaria in India: Retrospective and prospective view. Am J Trop Med Hyg 2007;77 6 Suppl: 69-78.  Back to cited text no. 2
    
3.
Mitra S, Abhilash K, Arora S, Miraclin A. A prospective study from South India to compare the severity of malaria caused by Plasmodium vivax, P. falciparum and dual infection. J Vector Borne Dis 2015;52:281-6.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Seshadri P, Dev AV, Viggeswarpu S, Sathyendra S, Peter JV. Acute pancreatitis and subdural haematoma in a patient with severe falciparum malaria: Case report and review of literature. Malar J 2008;7:97.  Back to cited text no. 4
    
5.
Mandal B, Das BK, Chatterjee SK, Guh P, Shai S, Sharma A, et al. Acute pancreatitis in a case of falciparum malaria - A rare presentation. J Assoc Physicians India 2011;59:731-3.  Back to cited text no. 5
    
6.
Mohapatra MK, Gupta MP. Falciparum malaria complicated with acute pancreatitis: A report of case series. J Vector Borne Dis 2011;48:177-9.  Back to cited text no. 6
    
7.
Sarma PS, Kumar RS. Abdominal pain in a patient with falciparum malaria. Postgrad Med J 1998;74:425-7.  Back to cited text no. 7
    
8.
Desai DC, Gupta T, Sirsat RA, Shete M. Malarial pancreatitis: Report of two cases and review of the literature. Am J Gastroenterol 2001;96:930-2.  Back to cited text no. 8
    
9.
Badhal SS, Irshad M, Badhal S, Yadav K. Acute on chronic pancreatitis masking falciparum malaria: A case report. Glob J Health Sci 2009;1:123-5.  Back to cited text no. 9
    
10.
Thapa R, Mallick D, Biswas B. Childhood Plasmodium falciparum malaria complicated by acute pancreatitis. Trop Doct 2010;40:184-5.  Back to cited text no. 10
    
11.
Kumar S, Jain AP, Vikas. Falciparum malaria presenting as acute pancreatitis. J Vector Borne Dis 2010;47:121-2.  Back to cited text no. 11
    
12.
Sharma V, Sharma A, Aggarwal A, Bhardwaj G, Aggarwal S. Acute pancreatitis in a patient with vivax malaria. JOP 2012;13:215-6.  Back to cited text no. 12
    
13.
Sundriyal D, Kumar N, Chandrasekharan A, Sharma B, Patnaik I, Kamble U. Fatal complications of Plasmodium vivax malaria: A series of three case reports. Ann Trop Med Public Health 2013;6:578-80.  Back to cited text no. 13
  Medknow Journal  
14.
Ghosh S, Das SK, Sharma A. Unusual presentation of acute pancreatitis in falciparum malaria. Trop Parasitol 2014;4:56-7.  Back to cited text no. 14
[PUBMED]  Medknow Journal  
15.
Singh J, Dinkar A, Atam V, Atam I, Jitendra S. An uncommon presentation of severe falciparum malaria: Acute pancreatitis. Int Res J Med Sci 2014;2:26-8.  Back to cited text no. 15
    
16.
Chanana L, Jegaraj MA, Kalyaniwala K, Yadav B, Abilash K. Clinical profile of non-traumatic acute abdominal pain presenting to an adult emergency department. J Family Med Prim Care 2015;4:422-5.  Back to cited text no. 16
[PUBMED]  Medknow Journal  



 
 
    Tables

  [Table 1], [Table 2], [Table 3]


This article has been cited by
1 Late onset acute pancreatitis in P. falciparum malaria An adverse reaction to intravenous artesunate?
Asmaa S. Mahdi,Mariya Molai,Juhi Chandwani,Huda Al Khalili,Hashim Ibrahim,Nenad Pandak,Faryal Khamis,Eskild Petersen
IDCases. 2018; 12: 124
[Pubmed] | [DOI]



 

Top
   
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Case Report
  Results
  Discussion
  Conclusion
   References
   Article Tables

 Article Access Statistics
    Viewed591    
    Printed6    
    Emailed0    
    PDF Downloaded93    
    Comments [Add]    
    Cited by others 1    

Recommend this journal