Rhabdomyolysis Causing Acute Renal Failure due to Plasmodium vivax Malaria: A Case Report

INTRODUCTION

Malaria is an acute febrile illness caused by Plasmodium parasites, which are endemic in India.¹ Malaria is caused by the bites of infected female Anopheles mosquitoes.¹ There are five parasite species that cause malaria in humans;^1,2 Plasmodium falciparum is having more complications.² The malaria parasite P. falciparum causes shock and multiorgan failure.² This causes hypovolemia, excessive hemolysis, disseminated intravascular coagulation, or multiorgan failure.² Another uncommon complication of P. falciparum malaria infection is rhabdomyolysis.^3–5 This causes metabolic acidosis and renal failure.^4,5 Kidney failure is a feature of black water fever caused by P. falciparum malaria, where hemoglobin from hemolyzed red blood cells leaks into the urine.^5–7 Also, Plasmodium vivax malaria is associated with a less severe disease. It does not lead to organ involvement in many cases, and most of the cases are mild in nature.^8–10 We report a case of P. vivax malaria infection causing severe rhabdomyolysis, which leads to acute renal failure.

CASE DESCRIPTION

A 28-year-old male patient presented with a 5-day history of fever and chills, as well as headache and body ache. He was put on paracetamol and further evaluated for his illness. He was fine and healthy for 5 days. He lives in an endemic area where malaria is common. The rapid malaria antigen kit test revealed that he had P. vivax malaria, which was confirmed by thick and thin smears (Table 1). His other lab parameters were within normal limits, and the test for dengue and leptospira was negative (Table 2). His serology tests for human immunodeficiency virus and hepatitis B and C viruses were negative. He does not have any addictions. His blood pressure was 140/90 mm Hg, his pulse rate was 110 beats/min, his respiratory rate was 20 beats/min, and his oxygen saturation was 98% on spirometry. He was hospitalized and started on intravenous fluids and antimalarial treatment with intravenous artesunate and paracetamol for his fever. On day 2 of hospitalization, he was complaining of bilateral lower limb weakness and severe pain during movement and on palpation, and he could not move his limbs. He also complains of blackish urine and decreased urine output. His creatine phosphokinase was very high, and his serum alanine aminotransferase was elevated. His renal function test was abnormal, showing acute renal failure, and his blood gases showed severe metabolic acidosis. He was diagnosed as having acute rhabdomyolysis causing renal failure. He has no history of any medical illness. He was placed on hemodialysis for his acute renal failure. After 7 days of hospitalization, he was better and started pouring urine; his urine output was 40–50 mL/hour. On the day 15 of hospitalization, he was discharged. On follow-up examinations, he was doing well, and all lab parameters were within normal limits. All necessary consent and permission were taken from patients and relatives for submission of reports to this article.

DISCUSSION

It is noted that P. falciparum malaria causes myoglobinuria, but the development of muscle necrosis is less likely.^4–6 Rhabdomyolysis causes acute renal failure due to the release of nephrotoxic myoglobin from muscles. Malaria associated with hypovolemia, hypotension, fever, and acidosis can increase renal failure. Rhabdomyolysis associated with P. vivax malaria is rare. Rhabdomyolysis in vivax malaria is caused by the P. vivax parasite’s direct effect on the muscle and the increased inflammatory response caused by the parasite’s killing.^6–8 A rapid malaria antigen test and thick and thin smear were used to confirm P. vivax infection. Rhabdomyolysis increases the severity of the acute renal failure.^9,10

CONCLUSION

It is to be noted that P. falciparum malaria causes myoglobinuria and is associated with rhabdomyolysis, giving rise to acute renal failure. However, P. vivax malaria is also associated with severe rhabdomyolysis and severe renal injury requiring hemodialysis.

ORCID

Ankush Balasaheb Kolhe https://orcid.org/0000-0002-8698-2548

REFERENCES

1. World Health Organization. Malaria. 2022. Available at: https://www.who.int/news-room/questions-and-answers/item/malaria?gclid=EAIaIQobChMI59D65ovd_QIVJClyCh3wJQ5FEAAYASAAEgL67PD_BwE. Accessed date: 17 November 2022.

2. World Health Organization. Guidelines for the Treatment of Malaria, 2nd edition. Geneva: World Health Organization, 2010. Available at: https://www.ncbi.nlm.nih.gov/books/NBK254225/#ch1.s2

3. Knodel JP, Moore GE. Rhabdomyolysis malaria. N Eng J Med 1993;329(16):1206–1207. DOI: 10.1056/NEJM199310143291618.

4. Kochar DK, Das A, Kochar SK, Saxena V, Sirohi P, Garg S, et al. Severe Plasmodium vivax malaria: A report on serial cases from Bikaner in northwestern India. Am J Trop Med Hyg 2009;80(2):194–198. PMID: 19190212.

5. Casado E, Gratacos J, Tolosa C, Martinez JM, Ojanguren I, Ariza A, et al. Antimalarial myopathy: An underdiagnosed complication? Prospective longitudinal study of 119 patients. Ann Rheum Dis 2006;65(3):385–390. DOI: 10.1136/ard.2004.023200.

6. Anstey NM, Russell B, Yeo TW, Price RN. The pathophysiology of vivax malaria. Trends Parasitol 2009;25:220–227. DOI: 10.1016/j.pt.2009.02.003.

7. Knobloch K, Rossner D, Gossling T, Lichtenberg A, Richter M, Krettek C. Rhabdomyolysis after administration of diclofenac. Unfallchirurg 2005;108(5):415–417. DOI: 10.1007/s00113-004-0874-z.

8. Allo JC, Vincent F, Barboteu M, Schlemer B. Falciparum malaria: An infectious cause of rhabdomyolysis and acute renal failure. Nephrol Dial Transpl 1997;12(9):2033–2034.

9. Allison RC, Bedsole DL. The other medical causes of rhabdomyolysis. Am J Med Sci 2003;326(2):79–88. DOI: 10.1097/00000441-200308000-00005.

10. Sinniah R, Lye W. Acute renal failure from myoglobinuria secondary to myositis from severe falciparum malaria. Am J Nephrol 2000;20:339–343. DOI: 10.1159/000013611.