Case presentation:
A18-years-old male, from Khartoum state, presented to the outpatient clinic on August 19th 2020 with fever and headache for 10 days during which he received cefixime 400 mg orally once a day (OD). Two days later, fever attacks continued progressively and the patient was further investigated for malaria infection which turned to be negative for malaria parasites using rapid diagnostic test. The patient did not show any improvement. On the initial clinical examination, he looked pale, fatigued, and not jaundiced or cyanosed. He was febrile (axillary Temp 39°C) and restless. His pulse rate was 130/min with normal volume and character. His respiratory rate was 18/min, and his blood pressure was 120/80 mmHg. The patient was not suffering from any chronic illness and had he is not addicted to drugs or any hypnoid or had any prolonged febrile illness over the last year. Clinical investigations of heart and abdomen were normal. The hematological investigation revealed severe anemia (Hb 7.1 gm/dl). Microscopic examination of thick and thin blood smears, performed at the day of admission was positive for P. falciparum . DNA from the blood was isolated and the 18S RNA region was amplified for detection of P. falciparum using the previously protocol 5. The result confirmed a current infection with P. falciparum .
It is noteworthy that the patient had recently traveled from Khartoum state to El-Gezira state, an area known for a high transmission rate of malaria. 5. The patient was not successfully treated with the initial malaria treatment artemether 80mg/lumefantrine 480mg (Comether®). Following the intake of the treatment, the patient suffered from a severe vomiting. After 4 days i.e., 19th of August, the patient was admitted to the medical health center for further examination. More importantly, he showed up with extraordinary reddish eyes indicating severe subconjunctival hemorrhage (Figure 1A).
Further health concerns were considered and investigated accordingly, and the patient tested negative for COVID-19, HBsAg, Anti-HCV, HIV-1 and HIV-2. Also, IgM antibodies for dengue virus, Rift valley fever and yellow fever virus were not detected. The ECG, ultrasonography of abdomen, and Chest X-ray were normal and no abnormality of the head CT scan. Urine analysis showed mild hematuria and microscopic examination of malaria infection was positive for P. falciparum . Considering the recent medical treatment, the patient was administered artesunate injections for 4 consecutive days (2.4 mg/kg, supplied with 12 mL of sterile 0.3 M pH 8.0 sodium phosphate buffer).
After the successful treatment course of artesunate, the patient was further investigated for the presence of malaria parasite, both microscopically and PCR assay. Both tests were negative, indicating a complete clearance of the parasite while the subconjunctival hemorrhage was still present. The patient’s blood pressure was 120/80 mmHg, pulse rate 110 beats/min, regular and respiratory rate was 18 breaths/min. Ophthalmic examination of the patient showed a visual acuity of 6/18 in both eyes with history of poor vision and family history of hypertension and diabetes mellitus type 1. Local examinations of the lid, cornea, iris, lens and fundus of both eyes were normal.
After 30 days of follow up, the patient became healthy with normal hematological parameters including Hb 12.1 gm/dl, total leukocyte count was 5800/mm3 and platelet count 175000/mm3. C-reactive protein (CRP) was <6 mg/dL. The patient recovered his normal vision and the subconjunctival hemorrhage was completely absorbed (Figure 1B).