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

Parameter	Result	Normal Range
Platelets	123 x10³/µL	150–450 x10³/µL
Bilirubin (Total)	33 µmol/L	<20 µmol/L
Conjugated Bilirubin	13 µmol/L	<5 µmol/L
ALP	112 U/L	40–130 U/L
GGT	309 U/L	<60 U/L
ALT	1581 U/L	<40 U/L
AST	904 U/L	<40 U/L
Protein	76.6 g/L	60–80 g/L

Imaging

• Liver Ultrasound: Shrunken liver with coarse echotexture, consistent with chronic liver disease.

Revised Diagnoses

1. Acute Liver Injury (drug-induced vs. alcoholic hepatitis).
2. Chronic Liver Disease (likely alcohol-related).
3. 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.

Disclaimer & Credit: All medical articles including ours, are informative and provide population trends not specific to individuals which can be very different. Always seek personalized medical advice from your doctor for individual healthcare decisions.

Posted March 25, 2025