Retinal Hemorrhages in Severe Non-cerebral Plasmodium vivax Malaria in an Adult

Abstract

A 30-year-male admitted with seven days history of intermittent fever with chills. He had history of Plasmodium vivax malaria two months back and incompletely treated with chloroquine. Patient was not suffering from any chronic illness and had no addiction. He had no history of seizures or altered sensorium. On examination his temperature was 38.5ºC by axilla. The blood pressure was 120/80 mmHg, pulse rate 110 beats/min, regular and respiratory rate was 18 breaths/min. He had severe pallor, icterus, conjuctival hemorrhage and splenomegaly. Signs of meningeal irritation were absent. Cardiovascular and respiratory system revealed no significant abnormality.Two days after admission in the hospital he had history of sudden painless decrease in the vision from both eyes. His visual acuity in left eye was 6/9 and 9/12 in right eye. External ocular muscle movements were normal. Both pupils were round, equal, regular and reacting to direct and consensual light stimulus. Fundus examination revealed multiple retinal hemorrhages with white center and roth spots in all quadrants of fundus of both eyes. Retinal vessels were found tortuous. Papilledema, retinal whitening and exudates were absent [ ABSTRACTMalaria is the most important parasitic diseases of humans and one of the leading causes of morbidity and mortality in tropical countries.Earlier Plasmodium vivax was considered as a benign infection, but now it is recognized as a cause of severe malarial disease. It causes severe malarial disease similar to those as Plasmodium falciparum including cerebral malaria, severe anaemia, severe thrombocytopenia, hepatic dysfunction, shock, acute respiratory distress syndrome (ARDS), acute renal failure, and pulmonary oedema. Malarial retinopathy includes retinal whitening, vessel changes, retinal hemorrhages and papilledema. However, retinal hemorrhages are very rare in Plasmodium vivax infestation. Hereby, we report a case of 30-year-old man, who presented with fever with chills and diminution of vision. He was found to have Plasmodium vivax infection with retinal hemorrhages. He was treated successfully with artisunate, primaquine and doxycycline, completely recovered after one month.keywords: Adult, Non-cerebral malaria, Retinopathy vivax and negative for Plasmodium falciparum. Confirmation of Plasmodium vivax and exclusion of Plasmodium falciparum was done by PCR. NS1 antigen and IgM antibodies were negative for dengue virus. The Chest X-ray and ECG were normal. Ultrasonography of abdomen showed mild hepatosplenomegaly. CT scan of head was done which had no significant abnormality. CSF examination and coagulation profile was normal. Urinanalysis was normal and blood culture was sterile. He was tested negative for HBsAg, Anti-HCV and HIV 1&2. In a case of Plasmodium vivax malaria these finding were suggestive of severe vivax disease. He treated with 120 mg Artisunate iv injections at 0, 12 and 24 h and then OD for seven days with 100 mg doxycycline orally for seven days. Two units of packed cell were transfused. After seven da...