Pulmonary thromboembolism as a rare complication of Plasmodium vivax malaria: A case report

Abstract

Key clinical message: Low threshold is required to suspect complications of Plasmodium vivax malaria. Pulmonary thromboembolism, though rare, should be considered as its complication in the presence of unexplained and sudden onset shortness of breath.

Abstract: The hypercoagulable complications of malaria typically manifest in the microvasculature. However, there are several cases of intracranial venous thrombosis caused by Plasmodium falciparum and Plasmodium vivax malaria, and there was one case report of pulmonary thromboembolism (PTE) due to P. falciparum. A 30-year-old Ethiopian male patient presented with sudden onset of shortness of breath for 3 days. He had also high-grade fever, chills, and rigors associated with loss of appetite and fatigue of similar duration. He was from malaria endemic area. He had a pulse rate of 108 beats per minutes, respiratory rate of 32 breaths per minute, oxygen saturation of 82% with atmospheric air and temperature of 38.9°C. Further examination revealed accentuation of pulmonary component of second heart sound. Complete blood count revealed mild anemia and peripheral blood film showed trophozoites of P. vivax. Pulmonary CT angiography showed filling defects in the right and left pulmonary arteries. The patient was diagnosed to have P. vivax malaria complicated by PTE. He was managed with intranasal oxygen, antimalarial agent, and anticoagulation. Upon serial evaluations on the third week and second month of follow up, he did not have complaints and physical examination was non-remarkable. Malaria is a protozoan disease with high mortality and morbidity. For a long time, severe cases of malaria were thought to be mostly caused by P. falciparum. However, recent evidences have shown a paradigm shift and we should remember that P. vivax can also cause severe malaria and this can be complicated by hypercoagulable conditions including PTE.

Keywords: Plasmodium vivax; malaria; pulmonary thromboembolism.

FIGURE 1

Trophozoites of Plasmodium vivax with amoeboid cytoplasm and large chromatin dot.

FIGURE 2

(A) There was S1 (yellow), Q3 (red), T3 (blue) pattern on limb leads with sinus tachycardia (short RR intervals shown with the star). (B) Right ventricular strain pattern (dominant R waves and T wave inversion) was seen on V1 and incomplete RBBB pattern seen in V2.

FIGURE 3

Axial (A) and coronal (B) sections pulmonary CT angiography showed filling defects in the right (blue arrows in A and B) and left pulmonary arteries (white arrow in A).

FIGURE 4

Axial sections pulmonary CT angiography (A and B) showed dilatation of right atrium (star in A) and right ventricle (arrowhead in A) with dilatation of IVC and reflux of contrast to hepatic veins (blue arrow in B).