Abstract Introduction Malaria, a mosquito-borne disease, remains a significant public health hazard in the pacific. Hemophagocytic Lymphohistiocytosis (HLH) is a rare but life-threatening complication of malaria with a very high morbidity and mortality. Cytokines mediated cardiac dysfunction is an exceptionally uncommon manifestation. We present a case of Malaria induced HLH, complicated by bradycardia. Case Presentation 69-year-old female underwent a 2-week birdwatching trip in Papua New Guinea, having neglected the recommended malaria prophylaxis. She presented with fever and fatigue, with laboratory findings notable for acute kidney injury, hyponatremia, anemia and thrombocytopenia. Peripheral Smear showed Plasmodium Falciparum parasitemia. She was admitted to the intensive care unit and initiated on IV artesunate. Despite appropriate therapy, her course worsened rendering evaluation for a complication and/or a secondary etiology. Extended laboratory workup showed worsening cytopenia, hyperfibrinogenemia, ferritin level of 1683 ng/ml, soluble IL-2 receptors of 35,564 U/ml fulfilling the HLH-2004 criteria. High dose steroids, IVIG, and anakinra were used for therapy. Course was further complicated by hypoxic respiratory failure, hypotension and bradycardia. Bradycardia seemed to be of isolated etiology given normal cardiac workup. Interestingly, 48 hours after clearing the parasite clearance bradycardia resolved rendering the cytokine-mediated inflammatory mechanism more likely than intrinsic cardiac dysfunction. Discussion HLH is rare, yet a life threatening complication. The concomitant occurrence of bradycardia is exceedingly uncommon. Bradycardia could be attributed to cytokine-mediated autonomic dysregulation or a direct inflammatory myocardial involvement are the proposed mechanism of bradycardia. Early Multidisciplinary involvement is key for timely management. Conclusion Severe Plasmodium falciparum infection may be complicated by secondary HLH. Proposed mechanism of the bradycardia favors cytokine induced autonomic dysregulation in contrary to direct inflammatory involvement. Antimalarial therapy combined with immune modulation are to survival. This abstract is funded by: None
Sarhan et al. (Fri,) studied this question.