Hepatic Encephalopathy in Malaria or Artesunate Toxicity: A Dilemma in Diagnosis

Abstract

Malaria remains an overwhelming problem with around 214 million cases reported worldwide each year. It remains a major health problem in the tropical developing countries and India accounts for 70% of the total malaria incidence in the Southeast Asia region. Even though, artesunate, a novel drug used in the treatment of chloroquine-resistant cases of Plasmodium falciparum infection causes transient transaminitis (elevation of alanine and aspartate transaminases), hepatitis and hepatic encephalopathy are very rare. We encountered a child with falciparum malaria, who accidently ingested artesunate tablets (16 mg/kg) and developed hepatic encephalopathy with clinical and biochemical improvement in a matter of 4 to 5 days. There are only a few reports of children with malaria developing hepatic encephalopathy, with or without coinfection with hepatotropic viruses. Also, there are no reports of hepatic encephalopathy secondary to artesunate overdose, creating a dilemma in diagnosis and management.

Keywords

malaria - hepatic encephalopathy - artesunate - children

• References

• 1 World Health Organization. World Malaria Report 2015. Available at: http://www.who.int/malaria/publications/world-malaria- report-2015/report/en/ . Accessed January 03, 2017
• 2 Dayanand KK, Punnath K, Chandrashekar VN. , et al. Malaria transmission under an unusual circumstance causing death in two siblings. Am J Trop Med Hyg 2016; 95 (01) 155-157
• 3 Severe falciparum malaria. World Health Organization, Communicable Diseases Cluster. Trans R Soc Trop Med Hyg 2000; 94 (Suppl. 01) S1-S90
• 4 Guidelines for the Treatment of Malaria. 2nd ed. Geneva: World Health Organization; 2010 Available at: http://www.ncbi.nlm.nih.gov/books/NBK254223/ . Accessed December 30, 2016
• 5 Atterbury CE, Maddrey WC, Conn HO. Neomycin-sorbitol and lactulose in the treatment of acute portal-systemic encephalopathy. A controlled, double-blind clinical trial. Am J Dig Dis 1978; 23 (05) 398-406
• 6 Festi D, Mazzella G, Parini P. , et al. Treatment of hepatic encephalopathy with non-absorbable antibiotics. Ital J Gastroenterol 1992; 24 (09) (Suppl. 02) 14-16
• 7 Hellerbrand C, Schattenberg JM, Peterburs P, Lechner A, Brignoli R. The potential of silymarin for the treatment of hepatic disorders. Clin Phytoscience 2016; 2 (01) 7
• 8 Bansal R, Kadhiravan T, Aggarwal P, Handa R, Biswas A, Wali JP. Plasmodium vivax and hepatitis E co-infection--a rare cause of malarial jaundice. Indian J Gastroenterol 2002; 21 (05) 207-208
• 9 Joshi YK, Tandon BN, Acharya SK, Babu S, Tandon M. Acute hepatic failure due to Plasmodium falciparum liver injury. Liver 1986; 6 (06) 357-360
• 10 Anand AC, Ramji C, Narula AS, Singh W. Malarial hepatitis: a heterogeneous syndrome?. Natl Med J India 1992; 5 (02) 59-62
• 11 Mishra SK, Mohanty S, Das BS. , et al. Hepatic changes in P. falciparum malaria. Indian J Malariol 1992; 29 (03) 167-171
• 12 Ahsan T, Rab SM, Shekhani MS. Falciparum malaria or fulminant hepatic failure?. J Pak Med Assoc 1993; 43 (10) 206-208
• 13 Srivastava A, Khanduri A, Lakhtakia S, Pandey R, Choudhuri G. Falciparum malaria with acute liver failure. Trop Gastroenterol 1996; 17 (03) 172-174
• 14 Premaratna R, Gunatilake AK, de Silva NR, Tilakaratne Y, Fonseka MM, de Silva HJ. Severe hepatic dysfunction associated with falciparum malaria. Southeast Asian J Trop Med Public Health 2001; 32 (01) 70-72
• 15 Thakur N, Sodani R, Chandra J, Mahto D. A rare case report of fatal fulminant hepatic failure in a child due to mixed vivax and falciparum infection. Case Rep Pediatr 2011; 2011: 614054
• 16 Centers for Disease Control and Prevention (CDC). Hepatitis temporally associated with an herbal supplement containing artemisinin - Washington, 2008. MMWR Morb Mortal Wkly Rep 2009; 58 (31) 854-856
• 17 Omotuyi IO, Nwangwu SC, Okugbo OT, Okoye OT, Ojieh GC, Wogu DM. Hepatotoxic and hemolytic effects of acute exposure of rats to artesunate overdose. African J Biochem Res 2008; 2 (05) 107-110