Splenic Infarction in Plasmodium Falciparum Malaria : Case Report and Review of Literature

Splenic involvement is frequently observed during malarial episode. This involvement may vary from simple asymptomatic splenic enlargement to serious complication such as hematoma, rupture, or infarction. Very few cases of splenic infarction in paediatric patients are reported in literature. This case report suggests that if a patient with malaria is complaining of left upper quadrant abdominal pain, and/or enlarging tender splenomegaly is observed during treatment, splenic infarct should be suspected and managed accordingly to avoid further life-threatening complications.


Introduction
M alaria is s ll the most important parasi c disease known to humans.Splenic involvement is frequently observed during malarial episode.This involvement may vary from simple asymptoma c splenic enlargement to serious complica on such as hematoma, rupture, or infarc on 1,2 .Very few cases of splenic infarc on in paediatric pa ents are reported in literature 3,4 .We report a case of splenic infarc on in falciparum malaria diagnosed by MRI abdomen.

The Case
A 14 year old female child was admi ed with complaints of fever and pain in abdomen.On examina on, pa ent had pallor, tender splenomegaly 5 cm below costal margin, hepatomegaly 3 cm below costal margin and severe anaemia (Hb 3gm/dl).Peripheral smear showed trophozoites of falciparum malaria and rapid diagnos c test was also posi ve.A diagnosis of splenic abscess was made on the basis of perisplenic collec on demonstrated on ultrasonography, for which intravenous an bio c (Inj Amoxycillin-clavlunic acid 90mg/kg/d thrice a day, inj amikacin 15mg/kg/day once a day and inj metronidazole 30mg/kg/day thrice a day) were added with intravenous Artesunate (2.4mg/kg/day once a day).But since the symptoms did not improved, MRI abdomen was performed which showed mul focal peripheral wedge shaped areas of altered signal in spleen sugges ve of splenic infarc on on T2W Fat suppression image (fi g. 1).As pa ent was not responding to Artesunate, an malarial was changed to Quinine (30mg/kg/day) which showed drama c improvement.The pa ent was discharged a er complete recovery.

Discussion
The occurrence of splenic infarct in P. falciparum is explained by the ability of its mature trophozoite and schizont forms to sequester in the deep venous microvasculature, whereas sequestra on is not a feature of P. vivax.What could have possibly led to splenic infarc on in these pa ents is sudden enlargement of the spleen in response to overwhelming infec on with subsequent hypoxic injury 3 .Another mechanism for splenic infarct in vivax cases may be from obstruc on produced by hyperplasia of the re cularlike cells located within the walls of venous sinuses 5 .A Medline search on PubMed (h p://www.ncbi.nlm.nih.gov/PubMed/) for 'malaria' AND splenic infarc on' revealed in 28 papers.On analysing the papers we found that 10 papers did not men on cases of splenic infarc on in there text.Remaining 17 papers were selected for this review of literature 3,[5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] .
The fi rst case was reported in 1975 by French authors Christoforov B et al which were associated with falciparum malaria 20 .On analysing all the papers ll date we found that total 24 cases of splenic infarc on in malarial pa ents were reported.Out of these 24 cases 9 were in pa ents with falciparum 3,5,12,14,15,16,17,18,19,20 while 11 cases were with P. vivax 5,6,7,8,9,11,13 and 3 cases had mixed infec on 5,11 .One case was of P. ovale reported in France in a young offi cer who had worked in Nigeria 10 .Majority of cases of splenic infarc on in malarial pa ents were reported from India and France.Of these cases ll date only 4 cases in paediatric pa ents have been reported, all of these are from India 6,11,14,15 .Most commonly used diagnos c modality for splenic infarc on was Ultrasonography that diagnosed it in 12 cases 5,6,8,14,15,17,18,20 .CT scan abdomen was needed in 8 of these cases 3,7,10,11,12,13,16,19 Out of which nine cases diagnosed by CT scan one case had normal USG fi ndings.MRI abdomen was done in only one case for confi rma on of diagnosis 10 .Only one case had complicated splenic haemorrhage and required surgical treatment 12 , rest all other cases resolved with conserva ve treatment.
Plasmodium vivax was the most common strain associated with splenic infarc on.In our case also we diagnosed splenic infarc on with MRI abdomen as diagnosed by other authors 10 although most of the authors used CT scan and USG for diagnosing the condi on.All the cases described in literature had excellent prognosis, except one 12 , with spontaneous recovery in most of the pa ents with an -malarial treatment as was there in our case.

Conclusion
Splenic infarc on may be a life threatening complica on due to splenic rupture or may be complicated by splenic abscess needing surgical interven on.So prompt evalua on of le subcoastal tenderness in malarial pa ents should be done.Evalua on should also include CT or MRI abdomen even if Ultrasound is normal, otherwise it is possible that many cases of splenic infarc on in malaria may be missed or may remain undiagnosed.

Fig 1 :
Fig 1: Showing areas of splenic infarc on (black arrow) in MRI T2W Fat suppression images.