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

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.