Intracellular cholestasis: a rare complication of malaria falciparum infection

Aside from acute viral hepatitides intracellular cholestasis is seen less often with the use of certain drugs, contrast media, leptospirosis and congenital hyperbilirubinaemias. Types of liver injuries complicating malaria usually take the form of acute hepatitis or haemolytic anaemias rather than cholestasis. We report here a rare presentation where a typical intracellular cholestatic picture complicated malaria falciparum in a patient residing in an endemic area.

A 55 year old bank manager presented with malaria fever and deep jaundice for investigations. CBC, LFT, renal function, coagulation profile, liver function test, viral hepatitis markers for HBV and HCV including PCR, U/S liver, MRI liver, CT brain, full septic screen, thin and thick Giemsa-stained blood films and ICT for malaria, leptospira Abs and ANA.

Total bilirubin 22 mg/dl, conjugated 19 mg/dl, ALT 49, AST 65, alkaline phosphatase 176 (normal), serum albumin 3.5 mg/dl, INR 0.9, urea 98 mg/dl, creatinine 2.3 mg/dl, Hb 8.8, platelet 263, WBC 11000, MCV 84, Coomb's test negative, haptoglobulin levels: normal, blood culture: negative, HBVDNA and HCVRNA: negative, ANA: negative, blood film and ICT for malaria: positive then turned negative after artemether treatment, leptospira Abs titres for six species including L haeorragiae at days 7, 14 and 60, were: <1/10 negative. Liver U/S normal, MRCP: normal and CT brain: normal patient fully recovered with anti-malarial agent artemether and short course of renal support (haemofiltration).

In cases of severe intracellular cholestasis malaria infection should be considered in the differential diagnosis particularly in malaria endemic localities. This rare complication of a common disorder is potentially treatable.