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14 Case Reports 165

Chloroquine phosphate 150 mg base and primaquine (30 mg) was started.
However, he remained febrile (38.4 °C) 24 h later. On day 3 of the admission, he
developed loose stools and lung examination revealed fine basal crepitations. Blood
smear examination showed that the malaria parasites were still present. On the
morning of day 4, he complained of breathlessness and lethargy. His body tempera-
ture surged to 39.2 °C.
Later that day, his dyspnoea worsen with haemoptysis and subsequent epistaxis.
Chest X-ray showed bilateral haziness up to the upper zone. Haematological inves-
tigation showed that his platelet count was 120,000/μL and the malaria parasite load
was reduced to 0.03%. Despite the lowering of parasitaemia, he progressed into
respiratory failure. He was intubated and ventilated. His anti-malarial treatment was
changed to IV quinine 850 mg (1 dose) and subsequently to IV artesunate 160 mg
(for 7 days).
On day 5 of admission, malaria parasites were completely cleared. However,
patient was still febrile with temperature of 40.8 °C. Patient subsequently developed
acute kidney injury, ARDS, and nosocomial sepsis and succumbed to his illness.

Source: Lau, Yee-Ling, Wenn-Chyau Lee, Lian-Huat Tan, Adeeba Kamarulzaman,
Sharifah Faridah Syed Omar, Mun-Yik Fong, Fei-Wen Cheong, and Rohela
Mahmud. “Acute respiratory distress syndrome and acute renal failure from
Plasmodium ovale infection with fatal outcome.” Malaria Journal 12, no. 1
(2013): 389.

Learning Points
1. Clinicians must advice travellers going to malaria endemic areas to be compliant
with malaria prophylaxis and to seek immediate treatment if they develop fever
during or after returning from the trip.
2. Travel history is essential in patients with febrile illness.
3. Early diagnosis and treatment of severe malaria with IV anti-malarial therapy is
important to prevent complications and death.

Case 9: Unusual Manifestation of Cutaneous Toxoplasmosis in a
HIV-Positive Patient
Case report: The patient was a 49-year-old HIV-positive Chinese male who was
diagnosed as having HIV infection many years ago. Despite treatment with highly
active anti-retroviral therapy with undetectable HIV RNA levels, he failed to fully
respond immunologically with CD4 cell level persistently below 100 cells/mm . He
3
presented with multiple hard and painful nodular lesions on both arms, hands and a
few on the chest. The nodules were non-tender and variable in size (0.5–3 cm in
diameter). Other parts of the body were not affected and no skin ulcers were
observed. Serological tests for anti-Toxoplasma IgG and IgM were negative.
Histopathology examination of the lesions showed numerous foci of macrophages
with intra- and extracellular organisms in the underlying dermis. These organisms
were crescent shaped, resembling the zoites of Toxoplasma gondii. The skin biopsy