ACALCULOUS CHOLECYSTITIS IN PLASMODIUM KNOWLESI INFECTION

Abstract

Introduction

Malaria infection has variable manifestations ranging from mild to severe illness with lethal complications. Gastrointestinal complications such as acalculous cholecystitis (ACC) is extremely rare. There are only a few cases reports worldwide for such complication in which Plasmodium Falciparum is commonly associated with. This case report is to highlight this rare malarial complication unusually associated with Plasmodium Knowlesi. 

Case report

A 34 year-old gentleman was referred from district hospital for acute abdomen. He presented with right hypochondriac pain for four days associated with jaundice and tea-coloured urine. He also had high grade fever with a history of hunting at jungle in Kuala Pilah the week before. Examination revealed pallor, deep jaundice and hypotension. The right hypochondriac region was tender and guarded with positive murphy sign and hepatomegaly. Blood results showed thrombocytopenia, anaemia, acute kidney injury and elevated liver enzymes with obstructive picture. Urgent ultrasound abdomen reported thickened gall bladder wall without calculi. In view of his hunting history, BFMP was done with 52102/0 Plasmodium Knowlesi parasites count. He was treated with intravenous artesunate and oral doxycycline for severe malaria. Supportive treatment including mechanical ventilation and dialysis were initiated from the beginning until he recovered well after twelve days of admission.

Discussion

AAC is commonly complicated from severe illness such as trauma, burns, sepsis or major surgery.  In malaria, the pathophysiology of AAC is multifactorial and not very well elucidated. Increased bile viscosity, gallbladder ischaemia and sequestration of parasites in the microvasculature are among the mechanisms suggested for AAC pathogenesis. Most of the cases with AAC usually associated with other features of severe malaria.

Conclusion

AAC may occur in Plasmodium Knowlesi infection. Thorough history taking and physical examination with appropriate investigations are important  in detecting this dreaded complication.