Case Presentation
A 30-year-old Ethiopian male patient presented with sudden onset shortness of breath of 3 days duration. 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 of the country. Otherwise, he had no history of recent surgery or trauma, no known chronic medical illness and no family history of similar illness.
He was acute sick looking with blood pressure of 100/70 mmHg, pulse rate of 108 beats per minutes, respiratory rate of 32 breaths per minute and body temperature of 38.9 degree Celsius. His oxygen saturation was 82% with atmospheric air improving to 92% with 3 liters of oxygen support through nasal cannula. Further examination revealed accentuation of pulmonary component of second heart sound. Otherwise, there were no pertinent positive findings on other systems.
Upon investigations, complete blood count revealed mild anemia with hemoglobin of 11g/dl (reference range: 12-16 g/dl) and normal white blood cell and platelet counts. Renal and liver function tests were within normal ranges. Peripheral blood film showed trophozoites of Plasmodium vivax with amoeboid cytoplasm and large chromatin dot (Figure 1). ECG was remarkable for sinus tachycardia, right ventricular strain pattern and S1T3Q3 pattern (Figure 2). Pulmonary CT angiography showed filling defects on the right and left pulmonary arteries (Figure 3) with dilatations of the IVC, right atrium and right ventricle (Figure 4).
After the patient was diagnosed to Plasmodium vivax malaria, he was started on chloroquine phosphate, which was taken for a total of 3 days (1000mg on day 1 and day 2 followed by 500mg on day 3) with paracetamol 1000mg PO per need. The cause of the respiratory distress was not initially clear and with the impression of acute respiratory distress syndrome to rule out pulmonary thromboembolism, he was put on intranasal oxygen maintaining at 3 liters per minute and empirically started on anticoagulation with unfractionated heparin 5000 IU IV stat followed by 17, 500 SC BID. Pulmonary CT angiography was done subsequently and the presence of pulmonary thromboembolism was confirmed. The final working diagnosis was Plasmodium vivax malaria complicated with pulmonary thromboembolism. On the 3rd day after initiation of the antimalarial and anticoagulation therapy, the patient showed significant improvement and he started to maintain his oxygen saturation with atmospheric air. Finally, anticoagulation was changed to rixaroxaban 15mg PO BID and he was discharged with appointment. Upon serial evaluations on the 3rd week and 2nd month of follow up, he did not have complaints and physical examination was non-remarkable.