Case 1-2011: A 60 years Old Male with Coma and Fever with Recent Travel to South Sudan

A 60 years –old business man admitted to the intensive care unit of the Endemic and Tropical Medicine Department, Faculty of Medicine , Zagazig University , Egypt because of deep coma , fever and tachypnea.The patient had history of recent travel to Juba, south of Sudan 2 weeks befor admission. 5 days after return from Sudan , he noticed fatigue and mild fever.He was given non-specific treatment. 5 days later jaundice appeared on his skin , he was admitted to private hospital in Zagazig .The investigation showed total bilirubin :10 mg/dl , direct 7 mg/dl , ALT:150 , AST :120,Hg :10 gm/dl ,platelets :110000 / dl .The patient was managed as having acute liver disease. Later on malaria parasite test (MP test) was done and revealed P. falciparum in thick and thin blood films.The patient was referred to Zagazig Fever Hospital with deterioration of conscious level , quinine was given intravenously without improvement . In the next day , the patient was referred to Tropical Medicine Intensive Care Unit. The patient was deeply comatose ,deeply jaundiced and pale, splenomegaly was found , bubbling chest crepitations were auscultated.The urine was black and the skin showed echymosis .The investigations showed total bilirubin :32 mg /dl, direct bilirubin 22 mg/dl, Hg :6 gm /dl ,platelets : 15000/dl , creatinin: 6 mg/dl , INR :7 ,PH: 7.31 , bicarbonate :12 mmol/l and glucose : 350 mg/dl. Hemoglobin was found in urine. Quinine was given by intravenous infusion in the dose of 20mg /kg loading dose then 10mg/ kg every 8 hours. Doxycyclin 100 mg /12 hours was given through the Ryle . Intravenous frusemide was given as well as oxygen inhalation as a measure against pulmonary edema , also chest consultation for the possibility of mechanical ventilation was requested.Transfusion of platelets, fresh frozen plasma ,and backed red blood cells were given . Intravenous fluids as glucose 10% with 15 unit regular insulin and Ringer lactate solution were given according to the CVP. Regular insulin according to blood glucose level was given every 6 hours subcutaneously. The patient showed no response after one day of extensive care and death was the the end due to multiple organ failure .