Plasmodium falciparum Malaria Retinitis; A Case Study at the Armed Forces Hospital, Jazan ‎

The patient was admitted to The Internal Medicine Department. On examination, He was fully conscious and oriented to time, place and persons. His vitals showed that the temperature 39.1 °C, the blood pressure 115/ 68 mm Hg, the pulse 112 beats per minute, the respiratory rate 22 breaths per minute, and the oxygen saturation 98 % in the room air. He started to develop  blurred vision and feeling difficulty with colours, his CNS examination  was unremarkable with normal cranial nerves examination , normal gait with no sensory or motor deficits in all limbs , pupils were equal, round, and reactive to light, and the neck was supple. His chest examination showed no crackles or wheezes. The heart sounds were regular, with no murmur. Abdominal examination was soft and lax on palpation with no organomegaly and no oedema in the lower limbs. There was no cervical, axillary, inguinal lymphadenopathy or skin rash.

A full laboratory work-up was requested and the results showed that the haemoglobin level was 10.5 g per decilitre, the mean corpuscular volume 94 fl, and the platelet count 62,000 per cubic millimetre. The WBC was 3.2 per cubic millimetre, with normal differential. The creatinine level 74 μmol per litre, the albumin level 3.8 g per decilitre, the total protein level 7.5 g per decilitre. Liver profile showed mild elevate aminotransferases with ALT 88 and AST 70. The prothrombin time of 18.6 , INR 1.5, partial thromboplastin time 43, and The LDH was 287 U per litre (normal value, 120 to 242), and the haptoglobin level was less than 10 mg per decilitre (normal value, 30 to 200). The reticulocyte production index was 1.3, and the direct Coombs test was negative. The peripheral blood smear revealed a Plasmodium falciparum microgametocyte using Giemsa stain with parasitemia level of 6 %.

Patient was started on Artesunate intravenous injections at a dose of 2.4 mg/kg given at 0, 12, and 24 hours and then once daily for a total of 7 days. Also he was given 3 tablets of Fansidar (sulfadoxine 500 mg –pyrimethamine 25 mg) as stat dose on the first day of admission as per The Saudi Ministry of Health guidelines.

The ophthalmology team was consulted: And on examination there was a decrease in acuity of vision of both eyes (right eye (6/60) and left eye (6/12), with marked impairment in his Colour vision of the red-green deficiency of 3/21 with Ishihara score for colour vision [7]. Fundus examination showed pigmented para-venous chorioretinitis, macular whitening and black pigmentation on the retinal vessels mainly at the periphery.

His ophthalmological examination records 1 year earlier during his annual check-up was normal with acuity of the right eye (6 / 6) and the left eye (6 / 6), with intact colour vision and normal fundus examination .

Based on that, the patient was diagnosed as severe Falciparum malaria with malaria retinitis, which is considered type of cerebral malaria.

During patient’s hospital stay, the patient reported improvement of his symptoms with resolution of fever and rigors. However, he still complained of blurred vision. Laboratory follow-up was done daily and showed improvement and laboratory results. On the day 7 his laboratory results showed that blood film for malaria was negative and his routine laboratory results showed that the haemoglobin level was 11.7 g per decilitre, , and the platelet count 220 ,000 per cubic millimetre. The WBC was 7.2 per cubic millimetre, with normal differential. The creatinine level 68 μmol per litre. Liver profile showed normal aminotransferases with ALT 32 and AST 20. The prothrombin time of 11.6, and INR 1.1. So, the patient was discharged from the hospital and was scheduled for a follow-up with the ID OPD as well as the ophthalmology OPD after 2 weeks.

Fundus fluorescein angiography during admission showed that there was Central retinal whitening with no cotton wool spots .there was no Obstruction of microcirculatory blood flow with normal perfusion of retinal blood flow, as shown in (figures 1 and 2) for the right eye and (figures 3 and 4) for the left eye.

Two weeks later, patient came to the Infectious disease clinic follow-up, and showed that he was clinically stable, his laboratory work-up showed negative blood film for malaria and his other routine laboratory investigations were within normal. The patient was also on a regular follow-up at the ophthalmology clinic and he was improving.

At 12 months, The patient full ophthalmology examination showed improvement of his vision of 6/6 in the right eye and 6/6 in the left eye, and his colour vision also showed marked improvement of red-green to 18/21 with Ishihara score for colour testing [7].

Fundus fluorescein angiography was done at 12 months, and showed the same malaria pigments along the blood vessels, but there was improvement of macular whitening with complete resolution. The patient retina photos at that visit at 12months are shown in figures 5, 6, 7 and 8) respectively.

After 12 months, OCT MACULA was done and was normal as shown in figures 9 and 10 below in figures 9 and 10.

Conclusion

Prober and on time management of Falciparum Malaria can save eyes and lead to complete resolution of visual acuity and colour vision.

Ethical consideration: All the information gathered from the patients was handled confidentially, and it was used only for research purpose.