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Posted March 25, 2025HEPATITIS
Case Study: Acute Malaria Complicated by Drug-Induced Liver Injury and Alcoholic Hepatitis in a 41-Year-Old Male
Introduction
This case highlights the diagnostic and therapeutic challenges in managing a patient with acute malaria who developed severe liver injury following antimalarial therapy. The interplay between antimalarial drugs, herbal medications, and occult alcohol use underscores the complexity of hepatotoxicity in tropical infections. The case emphasizes the importance of thorough medication reconciliation, laboratory monitoring, and consideration of multiple etiologies in patients with acute liver injury.
Case Presentation
Patient Demographics
Age/Gender: 41-year-old male
Occupation: Business professional
Social History: Denies smoking, alcohol use, or illicit drug use
Past Medical History: Unremarkable. No prior liver disease
Initial Presentation
Chief Complaint: Fever, bitterness in mouth, and generalized weakness for 7 days
Physical Exam:
Vitals: BP 122/81 mmHg, HR 84 bpm, Temp 36.6°C, Resp 16/min, BMI 18.52
General: Warm to touch
Abdomen: Soft, non-tender, no hepatosplenomegaly
Initial Workup
Peripheral Blood Smear: Plasmodium falciparum parasites
Echocardiogram: Normal wall motion, valves, and ejection fraction
Diagnosis & Treatment
Diagnosis: Acute malaria with anemia (Hb not specified)
Treatment:
Artemether 160 mg (single dose)
Coartem (Artemether/Lumefantrine) 80/480 mg twice daily for 3 days
Feroglobin (iron supplementation) daily
Follow-Up and Progression
1-Week Follow-Up
Symptoms: Resolution of fever but persistent weakness
Physical Exam:
Vitals: BP 105/78 mmHg, HR 77 bpm, Temp 36.8°C
Abdomen: Shrunken liver span (7th rib to costal margin on percussion)
Laboratory Findings
Platelets: 123 x10³/µL (Normal: 150–450 x10³/µL)
Bilirubin (Total): 33 µmol/L (Normal: <20 µmol/L)
Conjugated Bilirubin: 13 µmol/L (Normal: <5 µmol/L)
ALP: 112 U/L (Normal: 40–130 U/L)
GGT: 309 U/L (Normal: <60 U/L)
ALT: 1581 U/L (Normal: <40 U/L)
AST: 904 U/L (Normal: <40 U/L)
Protein: 76.6 g/L (Normal: 60–80 g/L)
Imaging
Liver Ultrasound: Shrunken liver with coarse echotexture, consistent with chronic liver disease
Revised Diagnoses
Acute Liver Injury (drug-induced vs. alcoholic hepatitis)
Chronic Liver Disease (likely alcohol-related)
Resolved Malaria
Differential Diagnosis and Key Analysis
Alcoholic Hepatitis: AST/ALT ratio >2:1, macrocytosis, elevated GGT, and shrunken liver
Drug-Induced Liver Injury (DILI): Artemether/lumefantrine or herbal medications
Viral Hepatitis: Ruled out via serology
Autoimmune Hepatitis: Negative autoimmune markers
Management and Outcome
Interventions
Discontinued hepatotoxic agents (herbal medications)
Supportive care: Vitamin K, lactulose, and nutritional support
Diagnostic workup confirmed occult alcohol use (elevated ethanol level)
Outcome
ALT/AST downtrend by 4 weeks; platelets normalized
Liver biopsy deferred due to clinical improvement
Learning Points
Liver function monitoring is mandatory during antimalarial therapy
Covert alcohol use may confound diagnoses; objective testing (e.g., urinary ethyl glucuronide) is critical
Multidisciplinary collaboration improves outcomes in complex cases
Conclusion
This case illustrates the overlap between infectious and hepatotoxic etiologies in a patient with acute malaria. Despite the patient’s denial of alcohol use, biochemical and imaging findings strongly suggested alcoholic hepatitis. The temporal association with antimalarial use necessitates vigilance for DILI, particularly in regions where herbal remedies are common.
References
Mathurin, P. et al. (2020). New England Journal of Medicine: "Management of Severe Alcoholic Hepatitis."
Chalasani, N. et al. (2021). Hepatology: "Diagnosis and Management of DILI."
WHO (2023). Guidelines for the Treatment of Malaria