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Year : 2014  |  Volume : 42  |  Issue : 4  |  Page : 151-153

A case of acute respiratory distress syndrome with Plasmodium vivax malaria

Department Of Medicine, Dr.Ram Manohar Lohia Hospital, New Delhi-01, India

Date of Submission18-Jul-2014
Date of Acceptance15-Sep-2014
Date of Web Publication21-Nov-2014

Correspondence Address:
Vikas T Talreja
Postgraduate Student, Department Of Medicine, Dr. Ram Manohar Lohia Hospital New Delhi-01
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DOI: 10.4103/1110-1415.145279

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Malaria is an important treatable cause of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) in the tropics and in the returning traveller in the nonendemic areas. ARDS is an important complication in severe, complicated Plasmodium falciparum malaria and has been described rarely in Plasmodium vivax and Plasmodium ovale malaria also. Malarial ALI/ARDS is more common in adults than in children. Pregnant women and nonimmune individuals are more prone to develop this condition. Increased alveolar capillary permeability resulting in intravascular fluid loss into the lungs appears to be the key pathophysiologic mechanism. The diagnosis of malaria is confirmed by slide microscopy supported by the use of rapid antigen tests. Patients with malarial ARDS should be managed in an ICU. Careful attention must be paid to haemodynamic stabilisation and optimising fluid balance. We hereby present a case of a 28-year-old man who presented with ARDS and P. vivax malaria demonstrated by slide microscopy.

Keywords: Plasmodium vivax malaria, acute respiratory distress syndrome (ARDS), acute lung injury (ALI), complicated malaria, India

How to cite this article:
Gupta P, Talreja VT, Dhananjaya M S, Mittal S. A case of acute respiratory distress syndrome with Plasmodium vivax malaria. Tanta Med J 2014;42:151-3

How to cite this URL:
Gupta P, Talreja VT, Dhananjaya M S, Mittal S. A case of acute respiratory distress syndrome with Plasmodium vivax malaria. Tanta Med J [serial online] 2014 [cited 2020 Nov 26];42:151-3. Available from: http://www.tdj.eg.net/text.asp?2014/42/4/151/145279

  Introduction Top

Malaria remains a global health problem with an estimated three to five hundred million new cases occurring each year. Although infection due to Plasmodium falciparum is responsible for the greatest overall morbidity and mortality, Plasmodium vivax contributes 70-80 million new cases to the annual worldwide burden of disease, especially in temperate regions [1]. As implied by its older, descriptive name, 'benign tertian malaria', infection due to P. vivax is generally not fatal. Acute respiratory distress syndrome is one of the well-recognized complications of malaria due to P. falciparum; however, it has been documented only rarely in association with P. vivax. It has recently been estimated that, in India, the total disability-adjusted life years lost due to malaria were 1.86 million years [2]. The key pathogenic mechanisms involving malaria are the erythrocyte sequestration and destruction, release of parasite and erythrocyte materials into circulation and release of proinflammatory cytokines such as interleukins-1, 6 and tumour necrosis factor-α. The key pulmonary pathogenic mechanism includes airflow obstruction, impaired ventilation, reduced gas transfer and increased pulmonary phagocytic activity [3,4]. We hereby present a case report of a 28-year-old man with acute respiratory distress syndrome with P. vivax malaria.

  Case Top

Mr. X, a 28-year-old resident of New Delhi, clerk by profession, came to Emergency Department of Dr. Ram Manohar Lohia Hospital, New Delhi with chief complaints of fever with chills and rigors for 2 days and breathlessness for 1 day. He said that he was apparently well 2 days ago when he started having fever of 103.2°F with chills and rigors followed by nonbilous nonblood-containing vomiting. Since 1 day, he had started feeling breathlessness and could not get down even from bed because of breathlessness. He is a nonsmoker, nonalcoholic, is nonasthmatic and has no past medical or surgical history. On examination, patient had a temperature of 102.8°F, blood pressure of 100/70, respiratory rate of 32/min, accessory muscles of respiration like alae nasi, sternocleidomastoid, cyanosed and agitated. Respiratory examination revealed bilateral polyphonic wheeze and crepts. Oedema was absent and no hepatosplenomegaly was present. Cardiac examination revealed normal S 1 , S 2 ; no murmur or gallop was present. SpO 2 revealed 55% oxygen at room air. Arterial blood gas revealed SpO 2 of 55% with PaCO 2 of 28 mmHg and PaO 2 of 34 mmHg. His haemoglobin was 12 g% with normal liver and kidney function tests. Patient was immediately shifted to ICU, ventilated with I : E ratio of 1 : 1, positive end-expiratory pressure of 15 cm H 2 O and tidal volume of 400 ml. His chest radiography revealed bilateral infiltrates with increased interstitial infiltrates and normal cardiac size. His ECG was normal; troponin T was negative and 2-day echo revealed normal left ventricular function with ejection fraction of 60% with no regional wall motion abnormalities. Hepatitis B anti-HCV HIV serologies were negative. Leptospiral, dengue, widal serologies were negative. Nasopharyngeal swab (RT-PCR) for H1N1 was negative. Blood and sputum cultures were sterile. Sputum for acid-fast bacilli and Gram stain were negative. Mantoux was negative. Peripheral smear revealed mature schizonts and ring forms of P. vivax. PCR DNA for P. falciparum was negative. Patient was initiated on broad-spectrum antibiotics, artesunate intravenous and mechanical ventilation, and his condition improved and he was removed from ventilator after 5 days. Subsequent chest radiography revealed clearing of infiltrates, and he was discharged 10 days after admission ([Figure 1], [Figure 2], [Figure 3], [Figure 4]).
Figure 1: Peripheral smear of the patient with schizont of Plasmodium vivax with more than 10 merozoites (Wright stain, ×1000).

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Figure 2: Peripheral smear showing ring form, schuffner and mature schizont at the same time (Wright stain, ×1000).

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Figure 3: Chest radiography of the patient revealing bilateral infi ltrates with normal cardiac shadow.

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Figure 4: Chest radiography at the time of discharge revealing clearing of infiltrates.

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  Discussion Top

P. vivax malaria is an important curable cause of ALI/ARDS. In endemic area, malaria should be considered as a possible aetiological cause in patients presenting with ARDS of obscure aetiology. Thick and thin peripheral blood smear examination usually confirms the diagnosis; sometimes, repeat examination may be helpful in detecting the parasite. Early institution of antimalarial treatment can be life saving, and initiation of treatment should not be delayed in patients with proven or strongly suspected malaria. Patients with ALI/ARDS are seriously ill and need to be managed in an ICU setting. They require assisted mechanical ventilation, monitoring and correction of anaemia and hypoglycaemia and prompt institution of renal replacement therapy and dialysis, if acute renal failure is also present. Further research is required to understand the pathogenetic mechanisms underlying the genesis of ALI/ARDS and to evolve appropriate mechanical ventilatory strategies.

  Acknowledgements Top

  References Top

Mendis K, Sina BJ, Marchensini P, Carter R. The neglected burden of Plasmodium vivax malaria. Am J Trop Med Hyg 2001; 64S:97-106.  Back to cited text no. 1
Kumar A, Valecha N, Jain T, Dash AP. Burden of malaria in India: retrospective and prospective view. Am J Trop Med Hyg 2007; 77:69-78.  Back to cited text no. 2
Day NP, Hien TT, Schollaardt T, Loc PP, Chuong LV, Chau TT, et al. The prognostic and pathophysiologic role of pro- and antiinflammatory cytokines in severe malaria. J Infect Dis 1999; 180:1288-1297.  Back to cited text no. 3
Taylor WR, Cañon V, White NJ. Pulmonary manifestations of malaria: recognition and management. Treat Respir Med 2006; 5:419-428.  Back to cited text no. 4


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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