Spontaneous haemothorax and haemoperitoneum in Plasmodium vivax malaria.

Although most cases of P. vivax malaria recover from the disease without complication, even if left untreated, a small percentage develops severe problems, usually involving the spleen (Maguire and Baird, 2010) — an organ that plays an important role in host defence against malarial parasites (Zingman and Viner, 1993). In most cases, haemothorax is caused by chest trauma or by invasive procedures such as the insertion of a central venous line, thoracentesis or pleural biopsy. Spontaneous or non-traumatic haemothorax is much less common and has a wide variety of causes, the most frequent being neoplasm and anticoagulant use; other causes include vascular rupture, pulmonary infarction, pleural endometriosis, and conditions that alter coagulation, such as haemophilia, thrombocytopenia and anti-platelet therapy (Martinez et al., 1992; Haro Estarriol et al., 2006). Small haemothoraces may be observed in stable patients but severe or unstable cases require surgical intervention. In the South Korean case described here, a CT scan revealed haemoperitoneum and bilateral haemothorax. There are several reports of haemoperitoneum (combined with a splenic rupture) in patients with malaria (Jacobs et al., 2005; Gockel et al., 2006; Jiménez et al., 2007) but, apparently, no previous reports of spontaneous haemothorax associated with the disease. In the present case, although the bleeding focus could not be accurately located in the CT scan, the haemoperitoneum was probably caused by a spontaneous splenic rupture with infarction. The probable cause of the haemothorax is harder to identify but there are two main possibilities. One is that the haemothorax was secondary to the haemoperitoneum. Anatomically, the pleural space is separated from the peritoneal space and it is uncommon for fluids from the two spaces to mix. In some ascitic conditions, however, such as liver cirrhosis, malignant neoplasm and (rarely) haemoperitoneum, peritoneal fluid can reach the pleural space (almost always the right pleural space), via direct transdiaphragmatic passage (Pratt and Shamblin, 1968). A second possible explanation for the haemothorax described here is that (independently of the splenic complications) a spontaneous haemorrhage happened in the patient’s supradiaphragmatic space. Human infection with P. vivax can induce anaemia and thrombocytopenia — via haemolysis, reduced cell deformity of (parasitised and nonparasitised) erythrocytes, increased splenic clearance, reduction of platelet survival, decreased platelet production, and increased splenic uptake of platelets — that are severe enough to provoke spontaneous bleeding and other haemostatic abnormalities (Gorski et al., 1993; Thapa et al., 2009; Bhatia and Bhatia, 2010). Physicians, who deal with malaria should consider the possibility of internal spontaneous bleeding, including haemothorax.

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