Reversible paralysis in pregnancy, thinking beyond malaria: a case report

Reversible paralysis in pregnancy, thinking beyond malaria: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Reversible paralysis in pregnancy, thinking beyond malaria: a case report Michaela Sous, Medson Boti, Brazilia Mose, Waseem Sous This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5993589/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Nov, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted 9 You are reading this latest preprint version Abstract Background: Malaria is a leading cause of pregnancy morbidity and mortality, and schistosomiasis is another infectious disease of poverty endemic in sub-Saharan Africa. We report the first case to our knowledge of reversible paralysis in pregnancy that highlights the diagnostic challenge of a dual burden of malaria and schistosomiasis in Malawi, a region endemic for both infectious diseases. Case Presentation: A 17-year-old gravida 1 para 0 presented to a rural health clinic in Malawi for evaluation of new-onset fever, headache, neck pain, and abdominal pain. She was diagnosed with Malaria and was prescribed artemisinin-based oral combination therapy. She presented to the district hospital twelve days after the initial presentation with new onset progressively worsening bilateral lower extremity weakness and pain. She reported being pregnant with an unknown last menstrual period. She lived close to a local river and swam frequently. Laboratory investigations showed malaria parasites on blood film, and despite treatment with intravenous artesunate she developed worsening lower extremity weakness and a neurogenic bladder. Urine studies showed ova and parasites suggestive of schistosomiasis. Presumptive treatment for neuroschistosomiasis was initiated with prednisone prior to administering praziquantel. The patient participated in physiotherapy and was ambulatory upon discharge three weeks later. Conclusion: This case demonstrates the dual burden of malaria and schistosomiasis manifesting as reversible paralysis in pregnancy. Additionally, this case highlights the danger of anchoring bias secondary to a co-existing malaria infection in a low-resource setting where diagnostic evaluation is limited. Public health policies and programmes are needed to eliminate these infectious diseases of poverty to achieve the Sustainable Development Goals. pregnancy malaria schistosomiasis infectious disease of poverty case report Background Malaria is a leading cause of pregnancy-related morbidity and mortality in sub-Saharan Africa, which may present with a wide array of symptoms[ 1 , 2 ]. Maternal symptoms and complications include fevers, chills, seizures, neurologic symptoms, haemolysis, anaemia, thrombocytopenia, acute respiratory distress syndrome, renal failure, and cardiovascular collapse[ 1 , 2 ]. Pregnancy complications include prematurity, intrauterine foetal demise, and low birth weight neonates[ 1 , 2 ]. The prevalence of malaria in pregnancy in Malawi ranges from 15-28.4%[ 3 ]. Schistosomiasis is a parasitic infection endemic in sub-Saharan Africa that affects over 40 million females of child-bearing age[ 4 ], and prevalence in pregnancy in endemic areas ranges from 5–67%[ 5 ]. Schistosomiasis can cause gastrointestinal, urogenital, and neurologic disease[ 6 – 9 ]. Neuroschistosomiasis manifestations include altered mental status, seizures, sensory disturbances, weakness in lower extremities, and bladder dysfunction[ 7 ]. This is the first case to our knowledge that highlights the diagnostic challenge of a dual burden of malaria and schistosomiasis in an endemic region manifesting as reversible paralysis in pregnancy. Case Presentation A 17-year-old gravida 1 para 0 female presented to a rural health clinic in Malawi with a 3-day history of fever, headache, neck pain, and abdominal pain. She was diagnosed with malaria based on positive rapid diagnostic testing and given oral treatment with Artemether-Lumefantrine 80–480 mg twice daily for 3 days. The patient’s fever, headache, neck pain, and abdominal pain did not improve, and she visited a traditional healer and tried unknown topical local medicines. Twelve days after the initial presentation to the rural health clinic, she was seen at a district hospital in Neno, Malawi. She sought higher level care due to persistence of her symptoms and new-onset progressively worsening weakness and pain in her bilateral lower extremities over seven days, culminating in an inability to ambulate. She did not provide a history suggestive of ascending weakness. She reported being pregnant with an unknown date of last menstrual period. Review of systems was negative for weight loss, cough, shortness of breath, chest pain, diarrhoea, constipation, joint pain, or vaginal bleeding. She denied any past medical history or recent trauma. She lived close to a local river and swam frequently. She was not married, though sexually active without using contraception. She denied any alcohol, tobacco, or recreational substance use. Her heart and lung examination were unremarkable. On the neurologic exam, she was awake, alert, and oriented to person, time, and place and had normal speech. She had flaccid weakness in her bilateral lower extremities graded 3/5 with no clonus. Motor strength graded 5/5 in bilateral upper extremities. There was decreased sensation to light touch in bilateral lower extremities. Pupils were round, equal, and reactive to light with intact extraocular movements. She had no facial asymmetry with intact sensation to light touch of the face. Her uvula elevated in midline without deviation. She had intact strength to shoulder shrug bilaterally. There was no tongue deviation. Patellar and Achilles reflexes were symmetrically decreased. She had a gravid non-tender abdomen. Digital rectal examination revealed normal rectal tone. Obstetric ultrasound was performed to assess the pregnancy and determine gestational age. Foetal heart rate was 141 beats per minute and foetal movements were visualized. Femur length measured 1.94 centimetres. Biparietal diameter measured 3.07 centimetres. Head circumference measured 11.26 centimetres. Abdominal circumference measured 8.78 centimetres. Using these measurements, the estimated foetal weight was calculated to be 124 grams, and the estimated gestational age was calculated to be 15 weeks and 3 days. Laboratory investigations revealed blood film with 906 Plasmodium falciparum per microliter and anaemia with a haemoglobin of 9.5 grams per decilitre. White blood cell counts and platelets were within normal limits. Her bloodwork was negative for hepatitis B and C, human immunodeficiency virus, and syphilis. Liver and renal function tests were not accessible due to reagent shortages. Given her neurologic symptoms, significant weakness, and positive malaria parasites on blood film, she was treated for severe malaria in pregnancy. The persistence of malaria parasites was likely due to treatment nonadherence; however, failure of previous malaria treatment could not be definitively ruled out. She was subsequently treated with intravenous artesunate 2.4 milligrams per kilogram every twelve hours for 3 doses. Then she was transitioned to oral Artemether-Lumefantrine 80–480 mg twice daily for 3 days. Despite the completion of direct observed malaria treatment in the hospital, she developed progressively worsening bilateral lower extremity weakness and urinary retention, requiring placement of a urinary catheter. Investigations one week after initial hospitalisation demonstrated no malaria parasites on blood film and a haemoglobin of 11.0 grams per decilitre, likely due to successful malaria treatment. Urine dipstick showed positive leukocyte esterase with more than 100 white blood cells per high power field on microscopy, negative nitrites, 1 + blood, 1 + protein, negative glucose, and specific gravity of 1.030. Urine ova and parasites showed large eggs with a terminal spine consistent with Schistosoma haematobium . The patient declined the recommended lumbar puncture. Presumptive treatment for neuroschistosomiasis was initiated. She was treated with prednisone 1 milligram per kilogram daily dosing to suppress the hypersensitivity reaction, prior to treatment with praziquantel 40 milligram per kilogram as a single dose[ 7 ]. She also participated in physiotherapy. The patient was discharged three weeks later, ambulating out of the hospital, and the prednisone was tapered off over three months based off existing neuroschistosomiasis literature[ 7 ]. Discussion and Conclusion Malaria and schistosomiasis are the two parasitic diseases that cause the highest number of global deaths[ 10 , 11 ]. Pregnancy increases vulnerability to many parasitic diseases including malaria and schistosomiasis, with the effect most pronounced in primigravidae and early gestation[ 2 , 5 ]. This patient’s neurologic symptoms in the early second trimester of pregnancy were initially attributed to severe malaria. When she failed to improve after adequate treatment, we broadened our differential diagnosis to include infectious transverse myelitis (including neuroschistosomiasis, poliomyelitis, human immunodeficiency-associated myelitis, hepatitis B and C myelitis, Mycobacterium tuberculosis myelitis), syphilis, multiple sclerosis, myasthenia gravis, and Guillain-Barré syndrome[ 6 ]. The finding of Schistosoma haematobium eggs in urine prompted our suspicion of neuroschistosomiasis. Additional diagnostic workup with lumbar puncture was declined by the patient. Further diagnostic evaluation could include neurologic imaging; however, this was unavailable due to resource limitations in rural Malawi. When available, magnetic resonance imaging can demonstrate signs of acute myelitis and spinal cord compression from granulomas[ 7 , 12 ]. Neuroschistosomiasis prognosis depends on early treatment to prevent irreversible damage[ 7 ]. Symptoms can include headaches, altered mental status, seizures, sensory disturbances, back pain, pain or weakness in lower extremities, paralysis, and bladder dysfunction[ 7 ]. Investigations including serology, ova and parasite testing of stool, urine, and cerebrospinal fluid, and computed tomography scan or magnetic resonance imaging of the nervous system can be negative; therefore, the diagnosis should be considered in patients with fresh water exposure in endemic areas even with negative testing[ 7 ]. Schistosomiasis is an underdiagnosed cause of myelopathy in endemic regions[ 7 ]. Limited evidence exists; however, one study from Malawi demonstrated schistosomiasis accounted for 16 of 33 investigated patients with nontraumatic spinal cord disorders[ 13 ]. Presumptive treatment for neuroschistosomiasis is recommended in Malawi for unexplained myelopathy[ 13 ], and treatment with praziquantel is safe in pregnancy[ 14 ]. In this case, definitive exclusion of all aetiologies of paralysis could not be performed due to resource limitations and patient’s declination of a lumbar puncture. However, the patient had significant improvement after treatment for neuroschistosomiasis, which was the most likely diagnosis for her condition within the context of rural Malawi. Schistosomiasis is endemic in areas afflicted by poverty, disproportionately affecting young people in rural regions with limited formal education and limited access to improved water sources, sanitation, and hygiene[ 8 , 9 , 15 , 16 ]. Schistosomiasis is associated with young primigravidae, maternal anaemia, and low birth weight neonates at delivery[ 4 , 8 , 16 ]. Animal studies showed schistosomiasis in pregnancy increased foetal, neonatal, and maternal mortality[ 17 , 18 ]. While human evidence surrounding adverse birth outcomes attributable to schistosomiasis remains mixed[ 19 ], obstetric case reports have shown associations with miscarriage[ 20 ], preeclampsia and foetal demise[ 21 ], and ectopic pregnancies[ 22 ]. Only one previous case report from 1987[ 23 ] highlighted transverse myelitis secondary to schistosomiasis in pregnancy. This report describes lower extremity paresis and urinary retention at 36 weeks gestational age in a multipara with positive Schistosoma ova antibodies, with negative urine studies for Schistosoma, negative Schistosoma rectal biopsy, and cerebrospinal fluid without Schistosoma antibodies[ 23 ]. In similarity to our presented case, this patient also received presumptive treatment and regained neurologic function. Although a lumbar puncture was not performed in our case, testing for viral causes of transverse myelitis in cerebrospinal fluid would not have been possible due to resource limitation in a district hospital. Our case highlights the dual burden of malaria and schistosomiasis in pregnancy, which is likely underreported as both conditions are endemic in similar areas due to similar risk factors as infectious diseases of poverty. Our case report highlights the danger of anchoring bias. Her co-infection with malaria limited further initial workup in a resource-limited setting. Anchoring biases have been reported in high-resource settings due to prevalent infectious diseases such as coronavirus[ 24 ], Lyme disease[ 25 ], acute bronchitis[ 26 ], and mumps[ 27 ]. Here we report a case of anchoring bias secondary to a co-existing malaria infection in a low-resource setting. Fixating on a common condition such as malaria in Malawi can influence medical judgement and negatively impact patient outcomes. In this case, a thorough history indicating frequent swimming in a local river prompted suspicion for alternate aetiologies of her neurologic symptoms. The patient shared that she was scared due to the progression of her symptoms after failed treatment attempts at the rural health clinic and through traditional methods. She was also fearful as she had not disclosed her pregnancy to her family. She was initially hesitant to engage in the therapeutic process, even declining some recommended interventions such as the lumbar puncture. Ultimately, she was grateful to regain muscle strength and the ability to walk. Given the burden of disease from malaria, pregnant women are given insecticide-treated nets and intermittent presumptive treatment with Sulfadoxine-Pyrimethamine[ 2 ]. There is a need for coordinated surveillance, prevention, and control of schistosomiasis in Malawi[ 28 , 29 ] with routine screening and treatment among pregnant women. In endemic areas, we recommend public health programs for prevention and treatment of schistosomiasis in pregnant women, which could be integrated in existing malaria prevention and intermittent treatment programs. Furthermore, coordinated public health efforts should also focus on accessibility of improved water sources, sanitation, and hygiene[ 10 , 28 , 30 ]. Eliminating infectious diseases of poverty including malaria and schistosomiasis are essential for achieving the Sustainable Development Goals. Declarations Ethics approval and consent to participate : SUNY Upstate Institutional Review Board does not require a review of case reports that do not meet the definition of human subject research. Case reports are generally carried out by a retrospective review of records and highlight a unique treatment, case, or outcome. As the collection and organization of information for such reports usually involves no data analysis or testing of a hypothesis, they do not involve a systematic investigation designed to contribute to generalizable knowledge. Written informed consent was given and obtained from the patient and her guardian to publish the case. Clinical trial number: not applicable. Consent for publication : Written informed consent for publication of this case report was obtained from the patient and her guardian. Details of the consent form may be disclosed on request for peer review purposes. Availability of data and materials : The data used during the current study are not publicly available to ensure that patient’s privacy is not compromised but are available from the corresponding author on reasonable request. Competing interests : The authors declare that they have no competing interests Funding : No funding was received Authors’ contributions: MS wrote the original draft of the manuscript and conducted the literature search. WS made substantial contributions to the conception of the work. MS, MB, BM, WS contributed to the writing, reviewing, and editing of the manuscript. All authors read and approved the final manuscript. Acknowledgements: We sincerely acknowledge the assistance of Partners in Health and the Malawi Ministry of Health in the comprehensive care for this patient. References Schantz-Dunn J, Nour NM: Malaria and pregnancy: a global health perspective . Rev Obstet Gynecol 2009, 2 (3):186-192. Boudová S, Cohee LM, Kalilani-Phiri L, Thesing PC, Kamiza S, Muehlenbachs A, Taylor TE, Laufer MK: Pregnant women are a reservoir of malaria transmission in Blantyre, Malawi . Malar J 2014, 13 :506. Boudová S, Divala T, Mawindo P, Cohee L, Kalilani-Phiri L, Thesing P, Taylor TE, Laufer MK: The prevalence of malaria at first antenatal visit in Blantyre, Malawi declined following a universal bed net campaign . Malar J 2015, 14 :422. Friedman JF, Mital P, Kanzaria HK, Olds GR, Kurtis JD: Schistosomiasis and pregnancy . Trends Parasitol 2007, 23 (4):159-164. Salawu OT, Odaibo AB: Maternal schistosomiasis: a growing concern in sub-Saharan Africa . Pathog Glob Health 2014, 108 (6):263-270. Vale TC, de Sousa-Pereira SR, Ribas JGR, Lambertucci JR: Neuroschistosomiasis mansoni: Literature Review and Guidelines . The Neurologist 2012, 18 (6):333-342. Ferrari TCAP, Moreira PRRMD: Neuroschistosomiasis: clinical symptoms and pathogenesis . Lancet neurology 2011, 10 (9):853-864. Murenjekwa W, Makasi R, Ntozini R, Chasekwa B, Mutasa K, Moulton LH, Tielsch JM, Humphrey JH, Smith LE, Prendergast AJ et al : Determinants of Urogenital Schistosomiasis Among Pregnant Women and its Association With Pregnancy Outcomes, Neonatal Deaths, and Child Growth . The Journal of Infectious Diseases 2019, 223 (8):1433-1444. Bartlett AW, Sousa-Figueiredo JC, van Goor RC, Monaghan P, Lancaster W, Mugizi R, Mendes EP, Nery SV, Lopes S: Burden and factors associated with schistosomiasis and soil-transmitted helminth infections among school-age children in Huambo, Uige and Zaire provinces, Angola . Infectious Diseases of Poverty 2022, 11 (1):73. Steinmann P, Keiser J, Bos R, Tanner M, Utzinger J: Schistosomiasis and water resources development: systematic review, meta-analysis, and estimates of people at risk . The Lancet Infectious Diseases 2006, 6 (7):411-425. Domingues ALC, Barbosa CS, Agt TFA, Mota AB, Franco CMR, Lopes EP, Loyo R, Gomes ECS: Spinal neuroschistosomiasis caused by Schistoma mansoni: cases reported in two brothers . BMC Infectious Diseases 2020, 20 (1):724. Matarneh AS, Abdullah W, Khan AA, Sadiq A, Farooqui K: A Case of Neuroschistosomiasis Presenting as Transverse Myelitis: The Importance of History Taking . Cureus 2020, 12 (11):e11445. Naus CW, Chipwete J, Visser LG, Zijlstra EE, van Lieshout L: The contribution made by Schistosoma infection to non-traumatic disorders of the spinal cord in Malawi . Ann Trop Med Parasitol 2003, 97 (7):711-721. Olveda RM, Acosta LP, Tallo V, Baltazar PI, Lesiguez JL, Estanislao GG, Ayaso EB, Monterde DB, Ida A, Watson N et al : Efficacy and safety of praziquantel for the treatment of human schistosomiasis during pregnancy: a phase 2, randomised, double-blind, placebo-controlled trial . Lancet Infect Dis 2016, 16 (2):199-208. Nour NM: Schistosomiasis: health effects on women . Rev Obstet Gynecol 2010, 3 (1):28-32. Mombo-Ngoma G, Honkpehedji J, Basra A, Mackanga JR, Zoleko RM, Zinsou J, Agobe JC, Lell B, Matsiegui PB, Gonzales R et al : Urogenital schistosomiasis during pregnancy is associated with low birth weight delivery: analysis of a prospective cohort of pregnant women and their offspring in Gabon . Int J Parasitol 2017, 47 (1):69-74. el-Nahal HM, Hassan SI, Kaddah MA, Ghany AA, Mostafa EA, Ibrahim AM, Ramzy RM: Mutual effect of Schistosoma mansoni infection and pregnancy in experimental C57 BL/6 black mice . J Egypt Soc Parasitol 1998, 28 (1):277-292. Willingham 3rd A, Johansen MV, Bøgh HO, Ito A, Andreassen J, Lindberg R, Christensen NO, Nansen P: Congenital transmission of Schistosoma japonicum in pigs . The American journal of tropical medicine and hygiene 1999, 60 (2):311-312. Gerstenberg J, Mishra S, Holtfreter M, Richter J, Davi SD, Okwu DG, Ramharter M, Mischlinger J, Schleenvoigt BT: Human Placental Schistosomiasis—A Systematic Review of the Literature . Pathogens 2024, 13 (6):470. Youssef AF, Abdine FH: Bilharziasis of the pregnant uterus . BJOG: An International Journal of Obstetrics & Gynaecology 1958, 65 (6):991-993. Obata NH, Kurauchi O, Kikkawa F, Yamada M, Fukuda Y, Itakura A: Preeclampsia with fetal death in a patient with schistosomiasis japonica . Archives of Gynecology and Obstetrics 1998, 261 (2):101-104. Bugalho A, Strolego F, Pregazzi R, Osman N, Ching C: Extrauterine pregnancy in Mozambique . International Journal of Gynecology & Obstetrics 1991, 34 (3):239-242. Truter PJ, van der Merwe JV: Transverse myelitis caused by schistosomiasis during pregnancy. A case report . S Afr Med J 1987, 71 (3):184-185. Abu-Rumaileh MA, Alsharif NM, Abdulelah M, Mueting S, Bader H: You Only Find What You Look for: Anchor Bias During the COVID-19 Pandemic . Cureus 2021, 13 (6):e15416. Aguirre LE, Chueng T, Lorio M, Mueller M: Anchoring Bias, Lyme Disease, and the Diagnosis Conundrum . Cureus 2019, 11 (3):e4300. Allen J, Miller BR, Vido MA, Makar GA, Roth KR: Point-of-care ultrasound, anchoring bias, and acute pulmonary embolism: A cautionary tale and report . Radiol Case Rep 2020, 15 (12):2617-2620. Iwai K, Tetsuhara K, Ogawa E, Kubota M: Hidden diagnosis behind viral infection: the danger of anchoring bias . BMJ Case Rep 2018, 2018 . Makaula P, Kayuni SA, Mamba KC, Bongololo G, Funsanani M, Musaya J, Juziwelo LT, Furu P: An assessment of implementation and effectiveness of mass drug administration for prevention and control of schistosomiasis and soil-transmitted helminths in selected southern Malawi districts . BMC Health Serv Res 2022, 22 (1):517. Makaula P, Sadalaki JR, Muula AS, Kayuni S, Jemu S, Bloch P: Schistosomiasis in Malawi: a systematic review . Parasit Vectors 2014, 7 :570. Grimes JET, Croll D, Harrison WE, Utzinger J, Freeman MC, Templeton MR: The relationship between water, sanitation and schistosomiasis: a systematic review and meta-analysis . PLoS neglected tropical diseases 2014, 8 (12):e3296-e3296. Additional Declarations No competing interests reported. Supplementary Files CAREchecklistBMCInfectiousDiseases.pdf Cite Share Download PDF Status: Published Journal Publication published 24 Nov, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 19 Sep, 2025 Editor assigned by journal 06 May, 2025 Reviews received at journal 05 May, 2025 Reviews received at journal 17 Apr, 2025 Reviewers agreed at journal 17 Apr, 2025 Reviewers agreed at journal 17 Apr, 2025 Reviewers invited by journal 17 Apr, 2025 Submission checks completed at journal 16 Apr, 2025 First submitted to journal 15 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5993589","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":444457422,"identity":"a1626d1a-dd72-45c7-a02b-cd093dd0c5ee","order_by":0,"name":"Michaela Sous","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAx0lEQVRIiWNgGAWjYNCCCgSTsYE4LWeAmA2imkgtjG2kaJFv7zH+dHPe4Tz5+c3PH3xgsJHdcICAFoMzZ8ykc7cdLjY4xmbYOIMhzZiwFokcM2aglsQNbAyGzTwMQAYhLfIzcow/5845nDi/jf1j8x+G/4S1MNzIMZDObTic2HCMx7CZgeEAYS0GZ46VSeccSwf6JadwZo9BsvFMgg5rb978OafGOk+++fiGDz8q7GT7CDoMChKglhKpHEnLKBgFo2AUjAIsAAAJQ0cdx3pp6AAAAABJRU5ErkJggg==","orcid":"","institution":"State University of New York, Upstate Medical University","correspondingAuthor":true,"prefix":"","firstName":"Michaela","middleName":"","lastName":"Sous","suffix":""},{"id":444457425,"identity":"fe44e40f-442c-4f49-9d65-7513e9403534","order_by":1,"name":"Medson Boti","email":"","orcid":"","institution":"Partners in Health, Malawi","correspondingAuthor":false,"prefix":"","firstName":"Medson","middleName":"","lastName":"Boti","suffix":""},{"id":444457427,"identity":"817ef002-dc42-4f41-952d-17b7cec2b937","order_by":2,"name":"Brazilia Mose","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Brazilia","middleName":"","lastName":"Mose","suffix":""},{"id":444457428,"identity":"e5caad9e-eedb-497a-b250-5a461d5c6b04","order_by":3,"name":"Waseem Sous","email":"","orcid":"","institution":"State University of New York, Upstate Medical University","correspondingAuthor":false,"prefix":"","firstName":"Waseem","middleName":"","lastName":"Sous","suffix":""}],"badges":[],"createdAt":"2025-02-09 16:38:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5993589/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5993589/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-025-12037-4","type":"published","date":"2025-11-24T15:57:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":97178260,"identity":"d2305639-9b30-4010-a41d-2ea3024a5c75","added_by":"auto","created_at":"2025-12-01 16:06:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1458093,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5993589/v1/38e3a2a3-3ffc-4046-bf9a-75c608560941.pdf"},{"id":80914388,"identity":"cf322c06-b914-4b79-8dae-fdbef78054b1","added_by":"auto","created_at":"2025-04-18 17:19:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":1366402,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklistBMCInfectiousDiseases.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5993589/v1/9ee56656682223432da24823.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Reversible paralysis in pregnancy, thinking beyond malaria: a case report","fulltext":[{"header":"Background","content":"\u003cp\u003eMalaria is a leading cause of pregnancy-related morbidity and mortality in sub-Saharan Africa, which may present with a wide array of symptoms[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Maternal symptoms and complications include fevers, chills, seizures, neurologic symptoms, haemolysis, anaemia, thrombocytopenia, acute respiratory distress syndrome, renal failure, and cardiovascular collapse[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Pregnancy complications include prematurity, intrauterine foetal demise, and low birth weight neonates[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The prevalence of malaria in pregnancy in Malawi ranges from 15-28.4%[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSchistosomiasis is a parasitic infection endemic in sub-Saharan Africa that affects over 40\u0026nbsp;million females of child-bearing age[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], and prevalence in pregnancy in endemic areas ranges from 5\u0026ndash;67%[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Schistosomiasis can cause gastrointestinal, urogenital, and neurologic disease[\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Neuroschistosomiasis manifestations include altered mental status, seizures, sensory disturbances, weakness in lower extremities, and bladder dysfunction[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This is the first case to our knowledge that highlights the diagnostic challenge of a dual burden of malaria and schistosomiasis in an endemic region manifesting as reversible paralysis in pregnancy.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 17-year-old gravida 1 para 0 female presented to a rural health clinic in Malawi with a 3-day history of fever, headache, neck pain, and abdominal pain. She was diagnosed with malaria based on positive rapid diagnostic testing and given oral treatment with Artemether-Lumefantrine 80–480 mg twice daily for 3 days. The patient’s fever, headache, neck pain, and abdominal pain did not improve, and she visited a traditional healer and tried unknown topical local medicines. Twelve days after the initial presentation to the rural health clinic, she was seen at a district hospital in Neno, Malawi. She sought higher level care due to persistence of her symptoms and new-onset progressively worsening weakness and pain in her bilateral lower extremities over seven days, culminating in an inability to ambulate. She did not provide a history suggestive of ascending weakness. She reported being pregnant with an unknown date of last menstrual period. Review of systems was negative for weight loss, cough, shortness of breath, chest pain, diarrhoea, constipation, joint pain, or vaginal bleeding.\u003c/p\u003e \u003cp\u003eShe denied any past medical history or recent trauma. She lived close to a local river and swam frequently. She was not married, though sexually active without using contraception. She denied any alcohol, tobacco, or recreational substance use.\u003c/p\u003e \u003cp\u003eHer heart and lung examination were unremarkable. On the neurologic exam, she was awake, alert, and oriented to person, time, and place and had normal speech. She had flaccid weakness in her bilateral lower extremities graded 3/5 with no clonus. Motor strength graded 5/5 in bilateral upper extremities. There was decreased sensation to light touch in bilateral lower extremities. Pupils were round, equal, and reactive to light with intact extraocular movements. She had no facial asymmetry with intact sensation to light touch of the face. Her uvula elevated in midline without deviation. She had intact strength to shoulder shrug bilaterally. There was no tongue deviation. Patellar and Achilles reflexes were symmetrically decreased. She had a gravid non-tender abdomen. Digital rectal examination revealed normal rectal tone.\u003c/p\u003e \u003cp\u003eObstetric ultrasound was performed to assess the pregnancy and determine gestational age. Foetal heart rate was 141 beats per minute and foetal movements were visualized. Femur length measured 1.94 centimetres. Biparietal diameter measured 3.07 centimetres. Head circumference measured 11.26 centimetres. Abdominal circumference measured 8.78 centimetres. Using these measurements, the estimated foetal weight was calculated to be 124 grams, and the estimated gestational age was calculated to be 15 weeks and 3 days.\u003c/p\u003e \u003cp\u003eLaboratory investigations revealed blood film with 906 \u003cem\u003ePlasmodium falciparum\u003c/em\u003e per microliter and anaemia with a haemoglobin of 9.5 grams per decilitre. White blood cell counts and platelets were within normal limits. Her bloodwork was negative for hepatitis B and C, human immunodeficiency virus, and syphilis. Liver and renal function tests were not accessible due to reagent shortages.\u003c/p\u003e \u003cp\u003eGiven her neurologic symptoms, significant weakness, and positive malaria parasites on blood film, she was treated for severe malaria in pregnancy. The persistence of malaria parasites was likely due to treatment nonadherence; however, failure of previous malaria treatment could not be definitively ruled out. She was subsequently treated with intravenous artesunate 2.4 milligrams per kilogram every twelve hours for 3 doses. Then she was transitioned to oral Artemether-Lumefantrine 80–480 mg twice daily for 3 days. Despite the completion of direct observed malaria treatment in the hospital, she developed progressively worsening bilateral lower extremity weakness and urinary retention, requiring placement of a urinary catheter.\u003c/p\u003e \u003cp\u003eInvestigations one week after initial hospitalisation demonstrated no malaria parasites on blood film and a haemoglobin of 11.0 grams per decilitre, likely due to successful malaria treatment. Urine dipstick showed positive leukocyte esterase with more than 100 white blood cells per high power field on microscopy, negative nitrites, 1 + blood, 1 + protein, negative glucose, and specific gravity of 1.030. Urine ova and parasites showed large eggs with a terminal spine consistent with \u003cem\u003eSchistosoma haematobium\u003c/em\u003e. The patient declined the recommended lumbar puncture.\u003c/p\u003e \u003cp\u003ePresumptive treatment for neuroschistosomiasis was initiated. She was treated with prednisone 1 milligram per kilogram daily dosing to suppress the hypersensitivity reaction, prior to treatment with praziquantel 40 milligram per kilogram as a single dose[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. She also participated in physiotherapy. The patient was discharged three weeks later, ambulating out of the hospital, and the prednisone was tapered off over three months based off existing neuroschistosomiasis literature[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e "},{"header":"Discussion and Conclusion","content":"\u003cp\u003eMalaria and schistosomiasis are the two parasitic diseases that cause the highest number of global deaths[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Pregnancy increases vulnerability to many parasitic diseases including malaria and schistosomiasis, with the effect most pronounced in primigravidae and early gestation[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This patient’s neurologic symptoms in the early second trimester of pregnancy were initially attributed to severe malaria. When she failed to improve after adequate treatment, we broadened our differential diagnosis to include infectious transverse myelitis (including neuroschistosomiasis, poliomyelitis, human immunodeficiency-associated myelitis, hepatitis B and C myelitis, \u003cem\u003eMycobacterium tuberculosis\u003c/em\u003e myelitis), syphilis, multiple sclerosis, myasthenia gravis, and Guillain-Barré syndrome[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe finding of \u003cem\u003eSchistosoma haematobium\u003c/em\u003e eggs in urine prompted our suspicion of neuroschistosomiasis. Additional diagnostic workup with lumbar puncture was declined by the patient. Further diagnostic evaluation could include neurologic imaging; however, this was unavailable due to resource limitations in rural Malawi. When available, magnetic resonance imaging can demonstrate signs of acute myelitis and spinal cord compression from granulomas[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Neuroschistosomiasis prognosis depends on early treatment to prevent irreversible damage[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Symptoms can include headaches, altered mental status, seizures, sensory disturbances, back pain, pain or weakness in lower extremities, paralysis, and bladder dysfunction[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Investigations including serology, ova and parasite testing of stool, urine, and cerebrospinal fluid, and computed tomography scan or magnetic resonance imaging of the nervous system can be negative; therefore, the diagnosis should be considered in patients with fresh water exposure in endemic areas even with negative testing[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSchistosomiasis is an underdiagnosed cause of myelopathy in endemic regions[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Limited evidence exists; however, one study from Malawi demonstrated schistosomiasis accounted for 16 of 33 investigated patients with nontraumatic spinal cord disorders[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Presumptive treatment for neuroschistosomiasis is recommended in Malawi for unexplained myelopathy[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], and treatment with praziquantel is safe in pregnancy[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In this case, definitive exclusion of all aetiologies of paralysis could not be performed due to resource limitations and patient’s declination of a lumbar puncture. However, the patient had significant improvement after treatment for neuroschistosomiasis, which was the most likely diagnosis for her condition within the context of rural Malawi.\u003c/p\u003e\u003cp\u003eSchistosomiasis is endemic in areas afflicted by poverty, disproportionately affecting young people in rural regions with limited formal education and limited access to improved water sources, sanitation, and hygiene[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Schistosomiasis is associated with young primigravidae, maternal anaemia, and low birth weight neonates at delivery[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Animal studies showed schistosomiasis in pregnancy increased foetal, neonatal, and maternal mortality[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. While human evidence surrounding adverse birth outcomes attributable to schistosomiasis remains mixed[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], obstetric case reports have shown associations with miscarriage[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], preeclampsia and foetal demise[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], and ectopic pregnancies[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOnly one previous case report from 1987[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] highlighted transverse myelitis secondary to schistosomiasis in pregnancy. This report describes lower extremity paresis and urinary retention at 36 weeks gestational age in a multipara with positive Schistosoma ova antibodies, with negative urine studies for Schistosoma, negative Schistosoma rectal biopsy, and cerebrospinal fluid without Schistosoma antibodies[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In similarity to our presented case, this patient also received presumptive treatment and regained neurologic function. Although a lumbar puncture was not performed in our case, testing for viral causes of transverse myelitis in cerebrospinal fluid would not have been possible due to resource limitation in a district hospital.\u003c/p\u003e\u003cp\u003eOur case highlights the dual burden of malaria and schistosomiasis in pregnancy, which is likely underreported as both conditions are endemic in similar areas due to similar risk factors as infectious diseases of poverty. Our case report highlights the danger of anchoring bias. Her co-infection with malaria limited further initial workup in a resource-limited setting. Anchoring biases have been reported in high-resource settings due to prevalent infectious diseases such as coronavirus[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], Lyme disease[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], acute bronchitis[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], and mumps[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Here we report a case of anchoring bias secondary to a co-existing malaria infection in a low-resource setting. Fixating on a common condition such as malaria in Malawi can influence medical judgement and negatively impact patient outcomes. In this case, a thorough history indicating frequent swimming in a local river prompted suspicion for alternate aetiologies of her neurologic symptoms.\u003c/p\u003e\u003cp\u003eThe patient shared that she was scared due to the progression of her symptoms after failed treatment attempts at the rural health clinic and through traditional methods. She was also fearful as she had not disclosed her pregnancy to her family. She was initially hesitant to engage in the therapeutic process, even declining some recommended interventions such as the lumbar puncture. Ultimately, she was grateful to regain muscle strength and the ability to walk.\u003c/p\u003e\u003cp\u003eGiven the burden of disease from malaria, pregnant women are given insecticide-treated nets and intermittent presumptive treatment with Sulfadoxine-Pyrimethamine[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. There is a need for coordinated surveillance, prevention, and control of schistosomiasis in Malawi[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] with routine screening and treatment among pregnant women. In endemic areas, we recommend public health programs for prevention and treatment of schistosomiasis in pregnant women, which could be integrated in existing malaria prevention and intermittent treatment programs. Furthermore, coordinated public health efforts should also focus on accessibility of improved water sources, sanitation, and hygiene[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Eliminating infectious diseases of poverty including malaria and schistosomiasis are essential for achieving the Sustainable Development Goals.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eEthics approval and consent to participate\u003c/u\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSUNY Upstate Institutional Review Board does not require a review of case reports that do not meet the definition of human subject research. Case reports are generally carried out by a retrospective review of records and highlight a unique treatment, case, or outcome. As the collection and organization of information for such reports usually involves no data analysis or testing of a hypothesis, they do not involve a systematic investigation designed to contribute to generalizable knowledge. Written informed consent was given and obtained from the patient and her guardian to publish the case. Clinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConsent for publication\u003c/u\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of this case report was obtained from the patient and her guardian. Details of the consent form may be disclosed on request for peer review purposes.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAvailability of data and materials\u003c/u\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data used during the current study are not publicly available to ensure that patient\u0026rsquo;s privacy is not compromised but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCompeting interests\u003c/u\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding\u003c/u\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNo funding was received\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eMS wrote the original draft of the manuscript and conducted the literature search. WS made substantial contributions to the conception of the work. MS, MB, BM, WS contributed to the writing, reviewing, and editing of the manuscript. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAcknowledgements:\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely acknowledge the assistance of Partners in Health and the Malawi Ministry of Health in the comprehensive care for this patient.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSchantz-Dunn J, Nour NM: \u003cstrong\u003eMalaria and pregnancy: a global health perspective\u003c/strong\u003e. \u003cem\u003eRev Obstet Gynecol \u003c/em\u003e2009, \u003cstrong\u003e2\u003c/strong\u003e(3):186-192.\u003c/li\u003e\n\u003cli\u003eBoudov\u0026aacute; S, Cohee LM, Kalilani-Phiri L, Thesing PC, Kamiza S, Muehlenbachs A, Taylor TE, Laufer MK: \u003cstrong\u003ePregnant women are a reservoir of malaria transmission in Blantyre, Malawi\u003c/strong\u003e. \u003cem\u003eMalar J \u003c/em\u003e2014, \u003cstrong\u003e13\u003c/strong\u003e:506.\u003c/li\u003e\n\u003cli\u003eBoudov\u0026aacute; S, Divala T, Mawindo P, Cohee L, Kalilani-Phiri L, Thesing P, Taylor TE, Laufer MK: \u003cstrong\u003eThe prevalence of malaria at first antenatal visit in Blantyre, Malawi declined following a universal bed net campaign\u003c/strong\u003e. \u003cem\u003eMalar J \u003c/em\u003e2015, \u003cstrong\u003e14\u003c/strong\u003e:422.\u003c/li\u003e\n\u003cli\u003eFriedman JF, Mital P, Kanzaria HK, Olds GR, Kurtis JD: \u003cstrong\u003eSchistosomiasis and pregnancy\u003c/strong\u003e. \u003cem\u003eTrends Parasitol \u003c/em\u003e2007, \u003cstrong\u003e23\u003c/strong\u003e(4):159-164.\u003c/li\u003e\n\u003cli\u003eSalawu OT, Odaibo AB: \u003cstrong\u003eMaternal schistosomiasis: a growing concern in sub-Saharan Africa\u003c/strong\u003e. \u003cem\u003ePathog Glob Health \u003c/em\u003e2014, \u003cstrong\u003e108\u003c/strong\u003e(6):263-270.\u003c/li\u003e\n\u003cli\u003eVale TC, de Sousa-Pereira SR, Ribas JGR, Lambertucci JR: \u003cstrong\u003eNeuroschistosomiasis mansoni: Literature Review and Guidelines\u003c/strong\u003e. \u003cem\u003eThe Neurologist \u003c/em\u003e2012, \u003cstrong\u003e18\u003c/strong\u003e(6):333-342.\u003c/li\u003e\n\u003cli\u003eFerrari TCAP, Moreira PRRMD: \u003cstrong\u003eNeuroschistosomiasis: clinical symptoms and pathogenesis\u003c/strong\u003e. \u003cem\u003eLancet neurology \u003c/em\u003e2011, \u003cstrong\u003e10\u003c/strong\u003e(9):853-864.\u003c/li\u003e\n\u003cli\u003eMurenjekwa W, Makasi R, Ntozini R, Chasekwa B, Mutasa K, Moulton LH, Tielsch JM, Humphrey JH, Smith LE, Prendergast AJ\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eDeterminants of Urogenital Schistosomiasis Among Pregnant Women and its Association With Pregnancy Outcomes, Neonatal Deaths, and Child Growth\u003c/strong\u003e. \u003cem\u003eThe Journal of Infectious Diseases \u003c/em\u003e2019, \u003cstrong\u003e223\u003c/strong\u003e(8):1433-1444.\u003c/li\u003e\n\u003cli\u003eBartlett AW, Sousa-Figueiredo JC, van Goor RC, Monaghan P, Lancaster W, Mugizi R, Mendes EP, Nery SV, Lopes S: \u003cstrong\u003eBurden and factors associated with schistosomiasis and soil-transmitted helminth infections among school-age children in Huambo, Uige and Zaire provinces, Angola\u003c/strong\u003e. \u003cem\u003eInfectious Diseases of Poverty \u003c/em\u003e2022, \u003cstrong\u003e11\u003c/strong\u003e(1):73.\u003c/li\u003e\n\u003cli\u003eSteinmann P, Keiser J, Bos R, Tanner M, Utzinger J: \u003cstrong\u003eSchistosomiasis and water resources development: systematic review, meta-analysis, and estimates of people at risk\u003c/strong\u003e. \u003cem\u003eThe Lancet Infectious Diseases \u003c/em\u003e2006, \u003cstrong\u003e6\u003c/strong\u003e(7):411-425.\u003c/li\u003e\n\u003cli\u003eDomingues ALC, Barbosa CS, Agt TFA, Mota AB, Franco CMR, Lopes EP, Loyo R, Gomes ECS: \u003cstrong\u003eSpinal neuroschistosomiasis caused by Schistoma mansoni: cases reported in two brothers\u003c/strong\u003e. \u003cem\u003eBMC Infectious Diseases \u003c/em\u003e2020, \u003cstrong\u003e20\u003c/strong\u003e(1):724.\u003c/li\u003e\n\u003cli\u003eMatarneh AS, Abdullah W, Khan AA, Sadiq A, Farooqui K: \u003cstrong\u003eA Case of Neuroschistosomiasis Presenting as Transverse Myelitis: The Importance of History Taking\u003c/strong\u003e. \u003cem\u003eCureus \u003c/em\u003e2020, \u003cstrong\u003e12\u003c/strong\u003e(11):e11445.\u003c/li\u003e\n\u003cli\u003eNaus CW, Chipwete J, Visser LG, Zijlstra EE, van Lieshout L: \u003cstrong\u003eThe contribution made by Schistosoma infection to non-traumatic disorders of the spinal cord in Malawi\u003c/strong\u003e. \u003cem\u003eAnn Trop Med Parasitol \u003c/em\u003e2003, \u003cstrong\u003e97\u003c/strong\u003e(7):711-721.\u003c/li\u003e\n\u003cli\u003eOlveda RM, Acosta LP, Tallo V, Baltazar PI, Lesiguez JL, Estanislao GG, Ayaso EB, Monterde DB, Ida A, Watson N\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eEfficacy and safety of praziquantel for the treatment of human schistosomiasis during pregnancy: a phase 2, randomised, double-blind, placebo-controlled trial\u003c/strong\u003e. \u003cem\u003eLancet Infect Dis \u003c/em\u003e2016, \u003cstrong\u003e16\u003c/strong\u003e(2):199-208.\u003c/li\u003e\n\u003cli\u003eNour NM: \u003cstrong\u003eSchistosomiasis: health effects on women\u003c/strong\u003e. \u003cem\u003eRev Obstet Gynecol \u003c/em\u003e2010, \u003cstrong\u003e3\u003c/strong\u003e(1):28-32.\u003c/li\u003e\n\u003cli\u003eMombo-Ngoma G, Honkpehedji J, Basra A, Mackanga JR, Zoleko RM, Zinsou J, Agobe JC, Lell B, Matsiegui PB, Gonzales R\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eUrogenital schistosomiasis during pregnancy is associated with low birth weight delivery: analysis of a prospective cohort of pregnant women and their offspring in Gabon\u003c/strong\u003e. \u003cem\u003eInt J Parasitol \u003c/em\u003e2017, \u003cstrong\u003e47\u003c/strong\u003e(1):69-74.\u003c/li\u003e\n\u003cli\u003eel-Nahal HM, Hassan SI, Kaddah MA, Ghany AA, Mostafa EA, Ibrahim AM, Ramzy RM: \u003cstrong\u003eMutual effect of Schistosoma mansoni infection and pregnancy in experimental C57 BL/6 black mice\u003c/strong\u003e. \u003cem\u003eJ Egypt Soc Parasitol \u003c/em\u003e1998, \u003cstrong\u003e28\u003c/strong\u003e(1):277-292.\u003c/li\u003e\n\u003cli\u003eWillingham 3rd A, Johansen MV, B\u0026oslash;gh HO, Ito A, Andreassen J, Lindberg R, Christensen NO, Nansen P: \u003cstrong\u003eCongenital transmission of Schistosoma japonicum in pigs\u003c/strong\u003e. \u003cem\u003eThe American journal of tropical medicine and hygiene \u003c/em\u003e1999, \u003cstrong\u003e60\u003c/strong\u003e(2):311-312.\u003c/li\u003e\n\u003cli\u003eGerstenberg J, Mishra S, Holtfreter M, Richter J, Davi SD, Okwu DG, Ramharter M, Mischlinger J, Schleenvoigt BT: \u003cstrong\u003eHuman Placental Schistosomiasis\u0026mdash;A Systematic Review of the Literature\u003c/strong\u003e. \u003cem\u003ePathogens \u003c/em\u003e2024, \u003cstrong\u003e13\u003c/strong\u003e(6):470.\u003c/li\u003e\n\u003cli\u003eYoussef AF, Abdine FH: \u003cstrong\u003eBilharziasis of the pregnant uterus\u003c/strong\u003e. \u003cem\u003eBJOG: An International Journal of Obstetrics \u0026amp; Gynaecology \u003c/em\u003e1958, \u003cstrong\u003e65\u003c/strong\u003e(6):991-993.\u003c/li\u003e\n\u003cli\u003eObata NH, Kurauchi O, Kikkawa F, Yamada M, Fukuda Y, Itakura A: \u003cstrong\u003ePreeclampsia with fetal death in a patient with schistosomiasis japonica\u003c/strong\u003e. \u003cem\u003eArchives of Gynecology and Obstetrics \u003c/em\u003e1998, \u003cstrong\u003e261\u003c/strong\u003e(2):101-104.\u003c/li\u003e\n\u003cli\u003eBugalho A, Strolego F, Pregazzi R, Osman N, Ching C: \u003cstrong\u003eExtrauterine pregnancy in Mozambique\u003c/strong\u003e. \u003cem\u003eInternational Journal of Gynecology \u0026amp; Obstetrics \u003c/em\u003e1991, \u003cstrong\u003e34\u003c/strong\u003e(3):239-242.\u003c/li\u003e\n\u003cli\u003eTruter PJ, van der Merwe JV: \u003cstrong\u003eTransverse myelitis caused by schistosomiasis during pregnancy. A case report\u003c/strong\u003e. \u003cem\u003eS Afr Med J \u003c/em\u003e1987, \u003cstrong\u003e71\u003c/strong\u003e(3):184-185.\u003c/li\u003e\n\u003cli\u003eAbu-Rumaileh MA, Alsharif NM, Abdulelah M, Mueting S, Bader H: \u003cstrong\u003eYou Only Find What You Look for: Anchor Bias During the COVID-19 Pandemic\u003c/strong\u003e. \u003cem\u003eCureus \u003c/em\u003e2021, \u003cstrong\u003e13\u003c/strong\u003e(6):e15416.\u003c/li\u003e\n\u003cli\u003eAguirre LE, Chueng T, Lorio M, Mueller M: \u003cstrong\u003eAnchoring Bias, Lyme Disease, and the Diagnosis Conundrum\u003c/strong\u003e. \u003cem\u003eCureus \u003c/em\u003e2019, \u003cstrong\u003e11\u003c/strong\u003e(3):e4300.\u003c/li\u003e\n\u003cli\u003eAllen J, Miller BR, Vido MA, Makar GA, Roth KR: \u003cstrong\u003ePoint-of-care ultrasound, anchoring bias, and acute pulmonary embolism: A cautionary tale and report\u003c/strong\u003e. \u003cem\u003eRadiol Case Rep \u003c/em\u003e2020, \u003cstrong\u003e15\u003c/strong\u003e(12):2617-2620.\u003c/li\u003e\n\u003cli\u003eIwai K, Tetsuhara K, Ogawa E, Kubota M: \u003cstrong\u003eHidden diagnosis behind viral infection: the danger of anchoring bias\u003c/strong\u003e. \u003cem\u003eBMJ Case Rep \u003c/em\u003e2018, \u003cstrong\u003e2018\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eMakaula P, Kayuni SA, Mamba KC, Bongololo G, Funsanani M, Musaya J, Juziwelo LT, Furu P: \u003cstrong\u003eAn assessment of implementation and effectiveness of mass drug administration for prevention and control of schistosomiasis and soil-transmitted helminths in selected southern Malawi districts\u003c/strong\u003e. \u003cem\u003eBMC Health Serv Res \u003c/em\u003e2022, \u003cstrong\u003e22\u003c/strong\u003e(1):517.\u003c/li\u003e\n\u003cli\u003eMakaula P, Sadalaki JR, Muula AS, Kayuni S, Jemu S, Bloch P: \u003cstrong\u003eSchistosomiasis in Malawi: a systematic review\u003c/strong\u003e. \u003cem\u003eParasit Vectors \u003c/em\u003e2014, \u003cstrong\u003e7\u003c/strong\u003e:570.\u003c/li\u003e\n\u003cli\u003eGrimes JET, Croll D, Harrison WE, Utzinger J, Freeman MC, Templeton MR: \u003cstrong\u003eThe relationship between water, sanitation and schistosomiasis: a systematic review and meta-analysis\u003c/strong\u003e. \u003cem\u003ePLoS neglected tropical diseases \u003c/em\u003e2014, \u003cstrong\u003e8\u003c/strong\u003e(12):e3296-e3296.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"pregnancy, malaria, schistosomiasis, infectious disease of poverty, case report","lastPublishedDoi":"10.21203/rs.3.rs-5993589/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5993589/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Malaria is a leading cause of pregnancy morbidity and mortality, and schistosomiasis is another infectious disease of poverty endemic in sub-Saharan Africa. We report the first case to our knowledge of reversible paralysis in pregnancy that highlights the diagnostic challenge of a dual burden of malaria and schistosomiasis in Malawi, a region endemic for both infectious diseases.\u003c/p\u003e\n\u003cp\u003eCase Presentation: A 17-year-old gravida 1 para 0 presented to a rural health clinic in Malawi for evaluation of new-onset fever, headache, neck pain, and abdominal pain. She was diagnosed with Malaria and was prescribed artemisinin-based oral combination therapy. She presented to the district hospital twelve days after the initial presentation with new onset progressively worsening bilateral lower extremity weakness and pain. She reported being pregnant with an unknown last menstrual period. She lived close to a local river and swam frequently. Laboratory investigations showed malaria parasites on blood film, and despite treatment with intravenous artesunate she developed worsening lower extremity weakness and a neurogenic bladder. Urine studies showed ova and parasites suggestive of schistosomiasis. Presumptive treatment for neuroschistosomiasis was initiated with prednisone prior to administering praziquantel. The patient participated in physiotherapy and was ambulatory upon discharge three weeks later.\u003c/p\u003e\n\u003cp\u003eConclusion: This case demonstrates the dual burden of malaria and schistosomiasis manifesting as reversible paralysis in pregnancy. Additionally, this case highlights the danger of anchoring bias secondary to a co-existing malaria infection in a low-resource setting where diagnostic evaluation is limited. Public health policies and programmes are needed to eliminate these infectious diseases of poverty to achieve the Sustainable Development Goals.\u003c/p\u003e","manuscriptTitle":"Reversible paralysis in pregnancy, thinking beyond malaria: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-18 17:19:21","doi":"10.21203/rs.3.rs-5993589/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-19T09:58:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-06T15:04:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-05T09:08:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-17T14:24:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"163965118750116756067534850633687562201","date":"2025-04-17T12:49:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168225779075406331984924400865545554128","date":"2025-04-17T11:57:19+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-17T10:33:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-16T23:40:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2025-04-16T00:22:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b15e639e-93e6-4003-afc7-3df534257814","owner":[],"postedDate":"April 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T15:59:53+00:00","versionOfRecord":{"articleIdentity":"rs-5993589","link":"https://doi.org/10.1186/s12879-025-12037-4","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2025-11-24 15:57:06","publishedOnDateReadable":"November 24th, 2025"},"versionCreatedAt":"2025-04-18 17:19:21","video":"","vorDoi":"10.1186/s12879-025-12037-4","vorDoiUrl":"https://doi.org/10.1186/s12879-025-12037-4","workflowStages":[]},"version":"v1","identity":"rs-5993589","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5993589","identity":"rs-5993589","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}