Intraleukocytic hemozoin pigments in complicated Plasmodium falciparum cerebral malaria

which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. A 33-year-old man presented with left hypochondrium pain and high-grade fever for 1 week and generalized convulsions followed by persistent unconsciousness. 2.8 mg/dL. His coagulation profile showed an international normalized ratio of 2.4, along with severe metabolic acidosis. Contrast-enhanced computed tomography showed diffuse cerebral edema. Leishman's stained peripheral film revealed abundant intraerythrocytic Plasmodium falciparum trophozoites and numerous brown, birefringent, cytoplasmic inclusions of hemozoin pigments in virtually all neutrophils (Figure, Leishman's stain, ×100). Some RBCs exhibited 2-3 trophozoites/cell. The parasitic load was markedly high (61.7×10 3 /L blood). The patient was immediately intubated. Despite adequate therapy, his condition deteriorated; he developed renal shutdown and acute respiratory distress syndrome and eventually died. A distinctive feature was the presence of intraleukocytic hemozoin in the malarial infestation. The presence of hemozoin, a biocrystal synthesized by hemoparasites to avoid free heme toxicity from erythrocytic invasion, in ＞5% of circulatory neutrophils is a poor prognostic marker, indicating severe disease.