Discussion:
Malaria remains a significant public health issue [11], and complications associated with the disease can be severe and potentially life-threatening [12]. This case report highlights the challenges of diagnosing and treating malaria in a young, previously healthy male who presented with fever, headache, and progressive illness. The patient was firstly given a wrong medication i.e cefixime, and thus the symptoms did not improve, and further investigation revealed severe anemia, low platelets, and ultimately a positive diagnosis of P. falciparummalaria through microscopic examination of blood smears and PCR testing. Importantly, the patient had recently traveled to an area known for high malaria transmission, underscoring the need for providers to consider travel history and geographic risk factors in the evaluation of febrile illness [12,13].
The patient’s subconjunctival hemorrhage was an unexpected complication, which may have been related to the malaria infection, the prior treatment with artemether/lumefantrine, or some other underlying factor. The negative test results for other infectious diseases and imaging procedures, such as head CT scan, echocardiography, ECG, and chest X-ray, suggest that the subconjunctival hemorrhage is unlikely to have resulted from any other identifiable underlying cause. Nonetheless, this case report underscores the importance of careful monitoring and follow-up of patients who present with malaria, as well as the need for further research into the full range of potential complications associated with this disease. The subconjunctival hemorrhage usually occurs when a tiny blood vessel underneath the conjunctiva breaks and often occurs without any obvious trauma to the eye. The main causes of the subconjunctival hemorrhage are not always known. However, trauma, violent coughing and sneezing, straining, or severe vomiting can lead to the break of the small blood vessels underneath the conjunctiva [14].
Ophthalmic changes due to malaria infection were mainly attributed to retinal hemorrhage which were frequently observed in P. falciparum infection, particularly with cerebral malaria in children; but uncommon in non-cerebral malaria [14]. Malarial retinopathy includes various retinal changes and signs including retinal whitening, vessel changes, retinal hemorrhages and papilledema [15]. The visual defects are usually reversible with complete recovery after treatment; but may rarely be irreversible [16]. Retinal hemorrhage is usually absorbed spontaneously over the period of one to four weeks without retinal sequelae and visual defect improved completely after successful treatment of malaria [17]. Few cases have been reported with irreversible visual defects [16]. While presented here in this case, subconjunctival hemorrhage was observed to be mainly induced by the vomiting which was initiated by the drug artemether/lumefantrine. This suggestion was also supported by the normal retinal investigation which excluded the red blood cells sequestration phenomena that induced the retinal hemorrhage signs, and also the stopping of the vomiting episodes after discontinuing the drug.
Pharmacovigilance studies (PV) were known to be the formal way of investigating treatment outcomes in patients and further follow up without severe adverse events [18].
It is worth mentioning that PV studies confirmed the effectiveness of artemether/lumefantrine in Sudan [19]. However, no any adverse events were noted, meanwhile, supporting the assumption of drug quality which was provided by the WHO [20]. The current case supports the assumption of the physiological outcomes of the currently used drug, since the internationally recommended dose of artemether/lumefantrine for patients (weight > 34 kg) is 40 mg artemether and 240 mg lumefantrine. Sudan malaria treatment protocol is based on the use of the higher recommended dose (80 mg artemether and 480 mg lumefantrine) [20].
One area in which this case report provides useful insights is in the inability of the initial treatment with artemether/lumefantrine to clear the patient’s malaria infection highlights the importance of following established protocols for managing falciparum malaria. The use of artesunate injections for four consecutive days, in accordance with WHO guidelines, was able to clear the patient’s infection, while providing a safer and more effective alternative to the initial treatment used.