Image 23: A young woman, recently from West Africa became febrile one week before admission. Incommunicado for 3 days, she was found  comatose, on her back in her apartment bed, and brought to  hospital. She arrived in status epilepticus and in renal failure, with 6% P. falciparum. Over the next 3 days, intubated and on dialysis, her initially normal looking toes on both feet became cool and purple/black. Her prothrombin time was normal, her peripheral pulses good. Her coma resolved by day 4, her parasitemia with quinine/doxycycline by day 4 and her renal failure in 2 weeks. She eventually lost the distal portions of the two worst toes. What was the toe problem?

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Image 23.  Malaria associated peripheral gangrene has been reported rarely in the literature in the past 25 years, although it is frequently mentioned in textbooks as a complication of severe P. falciparum infections. The mechanism is unclear but supposedly due to microvascular obstruction from sticky schizonts and RBC rheologic changes. A contribution from shock, as in our patient, would seem likely. Our patient initially received small iv doses (renal sparing, 2 µg/hr) of dopamine which has also been rarely associated with peripheral gangrene. The dopamine was stopped on day 2 of her admission when the toe changes were noted. The discoloration did not progress beyond day 4.