- InfezMed
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- 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 falciparum malaria in a pregnant woman. A Case report. Int. J. Infect. Dis. 9, 234-235, 2005. [5] Martin-Blondel G., Barry M., Porte L., et al. Impact of HIV infection on malaria in adults. Med. Mal. 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. [1] De Franceschi L., Sada S., Andreoli A., Angheben A., Marocco S., Bisoffi Z. Sickle cell disease and hyperreactive malaria splenomegaly (HMS) in young immigrants from Africa. Blood 106, 4415-4417, 2005. [2] Singh R.K. Hyperreactive malaria splenomegaly in expatriates. Travel Med. Infect. Dis. 5, 24-29, 2007. [3] Mount A.M., Mwapasa V., Elliott S.R. et al. Impairment of humoral immunity to Plasmodium falciparum malaria in pregnancy by HIV infection. Lancet 363: 1860-1867, 2004. [4] Giobbia M., Tonon E., Zanatta A., Cesaris L., Risoffi Z., Vaglia A. Late recrudescence of Plasmodium 34 2009