|Year : 2015 | Volume
| Issue : 3 | Page : 398-400
Plasmodium vivax infection manifesting as splenic abscess: A rare case report and review of literature
Gaurav Muktesh1, Nikhil Gupta1, Saroj Sahoo2
1 Department of Medicine, University College of Medical Sciences, New Delhi, India
2 Department of Medicine, Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi, India
|Date of Web Publication||15-May-2015|
Department of Medicine, University College of Medical Sciences, Dilshad Garden, Delhi - 110 095
Source of Support: None, Conflict of Interest: None
Incidence of malaria across the globe has constantly been on a rise, especially the tropics. Hence, it is of utmost importance to know its clinical presentation and complications including rare ones and treat them at the earliest. Spleen is a major organ affected by plasmodium. The changes in spleen because of malaria can range from asymptomatic enlargement to complications, such as splenic infarct, rupture, hemoperitoneum, hypersplenism, torsion, cyst, or abscess formation all of which are life-threatening if not treated. Splenic abscess due to any cause is a serious complication due to high-incidence of morbidity and mortality associated with it. Spleen abscess as a complication of malaria has been rarely described in the literature. We present to you a rare case of splenic abscess due to vivax species of plasmodium which was successfully treated conservatively.
Keywords: Complication, malaria, Plasmodium vivax, spleen abscess
|How to cite this article:|
Muktesh G, Gupta N, Sahoo S. Plasmodium vivax infection manifesting as splenic abscess: A rare case report and review of literature. Med J DY Patil Univ 2015;8:398-400
|How to cite this URL:|
Muktesh G, Gupta N, Sahoo S. Plasmodium vivax infection manifesting as splenic abscess: A rare case report and review of literature. Med J DY Patil Univ [serial online] 2015 [cited 2019 Oct 20];8:398-400. Available from: http://www.mjdrdypu.org/text.asp?2015/8/3/398/150502
| Introduction|| |
Plasmodium vivax is considered a benign infection. However, recently severe life-threatening malaria syndromes, frequently associated to Plasmodium falciparum, have been reported from Plasmodium vivax mono-infections. We now see complications as renal failure, encephalopathy, bleeding manifestations, etc., from P. vivax infection. Splenic abscesses are rare entities (autopsy incidence between 0.14% and 0.7%).  We describe such a rare case as a complication of P. vivax malaria.
| Case Report|| |
A 15-year-old male presented with complaints of high grade fever associated with chills and rigors for 6 days. He also had yellowish discoloration of sclera for 3 days and left sided upper abdominal pain for 2 days. On examination, patient was conscious and oriented to time place and person. Patient was febrile having a temperature of 102°F, blood pressure of 108/74 mm Hg in the right arm supine position and pulse rate of 104/min. Patient was found to be icteric. Spleen was tender and palpable up to 3-4 cm below the costal margin and was soft in consistency. His complete blood count revealed hemoglobin of 104 g/L, total leukocyte count of 6.5 × 10 9 /l and platelet count of 46 × 10 9 /l. Liver function tests showed total bilirubin of 82.08 μmol/l, predominant indirect component being 66.7 μmol/l. Peripheral smear for malaria parasite was negative, but optimal test was positive for P. vivax antigen. Of the other relevant blood investigations, patients lactate dehydrogenase levels were raised being 1334 U/l. Repeated blood cultures were sent, but were negative. Patient's ultrasound was done in view of abdominal pain, which revealed an abscess occupying the spleen with dimensions of 2.8 cm × 1.7 cm. His contrast-enhanced computed tomography scan of abdomen confirmed the abscess with dimensions of 3.2 cm × 1.9 cm as shown in [Figure 1] and [Figure 2]. A two-dimensional transthoracic echocardiography was done to look for evidence of infective endocarditis, but it did not reveal any abnormality. The abscess was drained under ultrasound guidance both for diagnosis and therapeutically (25 ml) from the spleen and optimal test was positive for P. vivax antigen. However, microscopic examination didn't reveal any form of P. vivax. Initially, ceftriaxone was given empirically. However, due to negative blood cultures and concomitant P. vivax positive in abscess fluid, ceftriaxone was stopped over a span of 4 days. Patient was given intravenous (IV) antimalarial drugs. Artesunate 90 mg was given intravenous (IV) at presentation then same dose was repeated at 12 h and 24 h. Artesunate IV along with IV clindamycin 600 mg BD was given for 7 days. Patient was shifted to weight based artesunate sulfadoxine-pyrimethamine combination therapy. Primaquine was added to treatment on the 7 th day of treatment. Patient recovered completely over a span of 2 weeks.
|Figure 1: Contrast-enhanced computed tomography scan of abdomen showing spleen abscess with dimensions of 3.2 cm × 1.9 cm|
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|Figure 2: Axial contrast-enhanced computed tomography scan of abdomen showing spleen abscess|
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| Discussion|| |
Splenic abscesses are rare entities (autopsy incidence between 0.14% and 0.7%).  Most common focus leading to splenic abscesses is the heart with bacterial endocarditis comprising of around 10-20% of cases.  Other septic foci include typhoid fever, malaria, urinary tract infections, osteomyelitis, otitis, etc. Splenic abscess may develop as an extension of infections in contiguous areas such as pancreatitis, retroperitoneal, subphrenic abscesses, and diverticulitis. Splenic trauma is the other major cause of abscesses. Splenic abscess may develop following hematoma or infarction of the spleen as in sickle cell anemia or leukemia's. Alcoholics, diabetics, and immunosuppressed individuals are more susceptible to developing a splenic abscess.
Splenic complications in malarial patients have been increasingly reported over the past decade or so. An enlarged spleen is found in 50-80% of malaria patients.  Around 25 cases of splenic rupture have been reported in the literature, since 1960,  the primary reason being a contained hematoma almost exclusively occurring during primary attack. 
Splenic infarction being rarer has been reported in around nine cases associated with malaria,  majority being consequent to P. falciparum infection.
To the best of our knowledge, splenic abscess has been reported prior in only three cases of malaria , to the best of our reviewed literature. All these three cases were found to be associated with P. falciparum species. It is believed that probably, it is depressed cellular and humoral immunity and micro infarcts/hematomas in spleen due to malaria that renders it susceptible to various organism such as Salmonella More Details, staphylococcus, etc. Abscess of the spleen caused by Salmonella enterica serovar. Enteritidis has been reported as a complication of P. falciparum malaria.  However in only one of the three cases, there has been a definite evidence of P. falciparum trophozoites and schizonts in the splenic abscess aspirate. 
To the best of our knowledge, we report the first case of splenic abscess as a result of P. vivax malaria with definite evidence of antigen in the splenic abscess aspirate. We hypothesize that by depressing the cellular and humoral immunity and by altering the local milieu in splenic pulp, malarial parasite might inhabit and cause complications like an abscess by its direct involvement. It is highly likely that these complications have been highly under diagnosed in the past because of low index of suspicion kept by treating doctors.
Furthermore, the trend of the management of splenic abscess has been shifting toward a more conservative approach. The spleen plays an integral role in the host defense against plasmodium and other intravascular parasites.  Every attempt at splenic salvage should be made to prevent future fatal malaria infections and possibility of remission.  This conservative approach is of all the more relevance to tropics as exposure to infective agents is particularly widespread and possibility of reinfection high. In our patient also a conservative approach was adopted and patient responded excellently to antimalarials and splenic abscess aspiration.
| Conclusion|| |
The most common cause of mortality in patients with splenic abscess (around 13-16% of patients  ) is late admission and diagnosis of the illness. Given the high prevalence of malaria in the tropics and ever growing international travelers to the endemics, there is a high probability of these complications rising in the future. Hence, malaria should also be kept as a possibility as a cause of spleen abscess and urgent measures should be taken to treat the same.
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[Figure 1], [Figure 2]