SHM Converge Scientific Abstract ePoster Gallery-Severe Malaria Triggering Hemophagocytic Lymphohistiocytosis: A Deadly Diagnostic Overlap

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This case highlights a dangerous diagnostic overlap between severe <strong>Plasmodium falciparum malaria</strong> and <strong>hemophagocytic lymphohistiocytosis (HLH)</strong>. A 58-year-old woman returned from Nigeria with one week of high fevers, fatigue, and altered mental status. Initial labs showed leukocytopenia, thrombocytopenia, transaminitis, and elevated lactate. A blood smear confirmed <strong>P. falciparum</strong> with parasitemia around 9–10%, and she was treated first with oral artemether/lumefantrine, then switched to intravenous artesunate because of clinical worsening and concern for poor oral absorption after prior Roux-en-Y gastric bypass.

Although parasitemia improved, the patient remained febrile and encephalopathic with worsening cytopenias and liver injury. Because her inflammation persisted despite parasite clearance, clinicians evaluated for HLH. Workup revealed marked <strong>hyperferritinemia</strong> and <strong>hypertriglyceridemia</strong>, along with splenomegaly and ongoing fever, meeting <strong>HLH-2004 diagnostic criteria</strong> for secondary HLH.

Treatment with <strong>high-dose IV methylprednisolone</strong>, followed by <strong>IVIG</strong> and <strong>dexamethasone</strong>, led to defervescence and improvement in platelet count, white blood cells, and transaminitis. The report emphasizes that severe malaria can itself cause multiorgan dysfunction, cytopenias, and mental status changes, but persistent abnormalities after parasitemia decreases should prompt suspicion for HLH. Early recognition is critical because HLH is a life-threatening hyperinflammatory syndrome that requires immunosuppressive therapy in addition to antimalarial treatment.

Asset Subtitle

Alexa Stynchula

Meta Tag

Author List Alexa Stynchula, Cecelia Hale

Category Clinical Vignettes

Concept Plasmodium falciparum malaria

Concept Severe Malaria

Concept Secondary hemophagocytic lymphohistiocytosis

Concept Multiorgan Dysfunction

Concept HLH-04 criteria

Distinguished Non-Finalist

Presenter Organization Parkview Health

Presenting Author Alexa Stynchula

Track Adult

Keywords

Plasmodium falciparum malaria

hemophagocytic lymphohistiocytosis

HLH

hyperferritinemia

hypertriglyceridemia

parasitemia

intravenous artesunate

methylprednisolone

IVIG

cytopenias

Plasmodium falciparum malaria

Severe Malaria

Secondary hemophagocytic lymphohistiocytosis

Multiorgan Dysfunction

HLH-04 criteria