- InfezMed

Le Infezioni in Medicina, n. 1, 33-34, 2009
Casi
clinici
Case
reports
P. falciparum malaria
recrudescence in a cancer
patient
Recrudescenza di malaria da P. falciparum
in un paziente neoplastico
Emanuele Focà1, Roberto Zulli2, Fabio Buelli1,
Massimiliano De Vecchi2, Antonio Regazzoli3, Francesco Castelli1
1
Institute for Infectious and Tropical Diseases, University of Brescia, Italy;
Department of Internal Medicine, Spedali Civili General Hospital, Brescia, Italy;
3
Biochemistry Laboratory, Spedali Civili General Hospital, Brescia, Italy
2
n CASE REPORT
A
60-year-old Italian engineer who had been
working for 33 years in Tanzania definitively returned to Italy in January 2006.
During his long stay in Africa, he recalled several malaria attacks, always treated with oral quinine without any sequelae. In November 2006 the
patient underwent endoscopic neurosurgery to
treat cerebral aneurismatic lesions, without complications. During hospitalization, splenomegaly
was reported without further investigations. In
December 2006, a lung Computed Tomography
(CT) revealed a 1-cm nodule that was biopsied.
Pathology confirmed the diagnosis of lung adenocarcinoma requiring lung lobectomy, which
was scheduled for early January 2007. In the
meantime, the patient suffered from a feverish attack on Christmas Day 2006 at his home, accompanied by headache, vomiting and profuse sweating. The patient spontaneously took paracetamol
and his symptoms disappeared. However, he was
hospitalized on 2 January 2007 at the Department
of Internal Medicine of the Spedali Civili General
Hospital in Brescia (Italy) to better investigate the
nature of his complaints. On entry, he had no
fever and was moderately anaemic (Hb=10.5
g/dL), with enlarged hyper-capturing spleen at
the Positron Emission Tomography (PET) that
had been carried out to stage his neoplastic disease. Serum gamma-globulins were also elevated (24.6%). IgM levels were not assessed. After a
few days of hospitalization, a routine blood cell
count revealed the presence of P. falciparum gametocytes that was confirmed by the consulting
Infectious Diseases specialist (Figure 1), thus sug-
Figure 1 - P. falciparum gametocytes in peripheral
thin blood films.
gesting that the previous fever episode might be
ascribed to malaria attack. Despite the fact that
gametocytes are not pathogenic to men, a complete antimalarial course of atovaquone-proguanil
and subsequent pyrimethamine-sulfadoxine was
given to prevent possible future recrudescence
following the scheduled lung lobectomy and subsequent chemotherapy. Lobectomy was indeed
carried out on 26 January 2007 (histology: neuroendocrin carcinoma). The patient then decided
to return to Tanzania and was lost to follow-up.
n COMMENTS
P. falciparum parasites are known to persist
asymptomatically in those exposed for long periods of time to malaria infection in highly en-
33
2009
demic areas. Hyper-reactive Malaria Splenomegaly may then develop in both local people
and expatriates, as was possibly the case in our
patient [1, 2]. However, the pathogenetic mechanisms leading to P. falciparum persistence are
still unknown to a large extent. Following immune suppression, recrudescence may occur.
This is particularly frequent in pregnancy-related immune-tolerance, even long after leaving a
malaria endemic area, in immune-compromised HIV patients and following splenectomy
or otherwise impaired spleen function [3-7].
Malaria is also a well known cause of immune
suppression [8].
Our case underlines the possibility that even
long-term expatriates may suffer from P. falciparum malaria recrudescence when immune
suppression occurs, as was the case in our cancer patients. Physicians in western countries
should consider malaria in the case of fever in
returning long-term expatriates with debilitating conditions.
SUMMARY
Persons living for long periods of time in malaria
hyper-endemic areas may suffer from hyper-reactive malarial splenomegaly (HMS), a frequent cause
of splenomegaly in such areas. Splenomegaly and
sub-microscopic P. falciparum parasitaemia are hallmarks of HMS.
Spleen has been suggested to play a protective antimalarial role and splenectomy may trigger sympto-
matic malaria attacks. Other causes of immune suppression may possibly reactivate latent malaria parasites. We report the case of an Italian 60-year-old
male, who had spent 33 years in sub-Saharan
Africa, who experienced a P. falciparum malaria attack 12 months after his return to Italy, concomitantly with a diagnosis of lung carcinoma possibly
impairing his immune system.
RIASSUNTO
I soggetti che trascorrono lunghi periodi di tempo in
area di iperendemia malarica possono sviluppare Splenomegalia Iperreattiva Malarica (HMS), una frequente
causa di splenomegalia tropicale con parassitemia submicroscopica di P. falciparum.
Esistono evidenze che la milza potrebbe giocare un
ruolo protettivo nei confronti della infezione malarica,
come testimoniato dalla recrudescenza che si osserva
in corso di splenectomia. Analogamente, altre cause di
immunodepressione possono riattivare i parassiti malarici latenti.
Viene descritto il caso di un paziente italiano di 60 anni, che ha trascorso 33 anni in Africa sub-sahariana e
che ha sviluppato malaria da P. falciparum 12 mesi dopo il suo ritorno in Italia in concomitanza con la diagnosi di adenocarcinoma bronchiale.
n REFERENCES
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Infect. 37, 629-636, 2007.
[6] Bidegain F., Berry A., Alvarez M., et al. Acute
Plasmodium falciparum malaria following splenectomy for suspected lymphoma in 2 patients. Clin. Infect. Dis. 40, e97-100, 2005.
[7] Greenwood T., Vikerfors T., Sjoberg M., Skeppner G., Farnert A. Febrile Plasmodium falciparum malaria 4 years after exposure in a man with sickle cell disease. Clin. Infect. Dis. 47, e39-41, 2008.
[8] Schofield L., Mueller I. Clinical immunity to
malaria. Curr. Mol. Med. 6, 205-221, 2006.
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