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.