The Hyper-Reactive Malarial Splenomegaly- A Rare and Severe Form of Chronic Plasmodial Infection: About A Case

Introduction: Hyper-reactive malarial splenomegaly is a leading cause of large tropical splenomegaly in endemic zones. Here, we report a case diagnosed in a young woman living in Guinea, a malaria-endemic area. Clinical observation: A 32-year-old Guinean woman with a history of repetitive malaria infection episodes presented to the internal medicine outpatient clinic with 5-months history of voluminous mass of the left flank extending to the umbilical region, with no pain and progressive onset, and a sensation of early satiety accompanied by eructation and epigastralgia worsened with eating. Digestive examination revealed a large, firm, smooth-surfaced, painless splenomegaly with a splenic size 20 centimeters below the left costal margin on the mid-clavicular line and measuring 28 centimeters in its long axis. The initial complete blood count showed a normocytic normochromic anemia with lymphocytosis, neutropenia and thrombocytopenia. The erythrocyte sedimentation rate (ESR) was 65 mm at the first hour. Malaria rapid diagnostic test (RDT) was positive for Plasmodium. The thick blood smear had come back negative. Serum protein electrophoresis demonstrated a decrease in albumin to 36.5 g/l and an increase in gamma globulins to 19.1 g/l. Immunoelectrophoresis of serum proteins showed a polyclonal increase in IgG. Abdominal ultrasound revealed enormous homogeneous splenomegaly (180 millimeters). The diagnosis of Hyper-reactive malarial splenomegaly was made on the basis of diagnostic criteria established by Fakunle et al in 1981. Our patient presented with enlarged splenomegaly, negative thick smear, positive RDT for plasmodium, elevated erythrocyte sedimentation rate, lymphocytosis, pancytopenia, and a good therapeutic response. Atovaquone-proguanil 250mg/100 mg at a dose of 1000mg/400 mg, i.e. 4 tablets taken as a single dose over three days, was initiated, then relayed by alternance of doxycycline 100 mg (100 mg once daily) for 1 month and nivaquine 100 mg ..........