Blind, breathless, and paralysed from benign malaria

In September, 2009, a 56-year-old man presented to another hospital with dyspnoea, rigors, and headache, 10 days after returning from Pakistan. He had mild asthma but was otherwise well with no history of raised blood pressure or anaemia, and not on medications. On admission, he was tachycardic with episodes of high fever and normal oxygen saturation level (98% on air). His platelet count was 115×109 per L, and C-reactive protein was 102 mg/L. A chest radiograph was normal. A blood film showed Plasmodium vivax. He was started on oral quinine 600 mg three times a day, because of the disease severity. Over the next 2 days he had episodes of high fever up to 40°C, and bilateral chest infiltrates on radiography, which prompted intravenous quinine therapy and the addition of empirical amoxicillin and clarithromycin. He was then transferred to our hospital, started on oral chloroquine, and mechanically ventilated for 13 days for type I respiratory failure. Our patient's radiographs were consistent with acute respiratory distress syndrome (ARDS) and his echocardiogram was normal. Over the next 7 days he had episodes of high fever despite negative blood films, blood cultures, and PCR for respiratory syncytial virus, influenza A, B, H1N1, para-influenza types 1, 2, 3 and adenovirus.