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.