similar clinical pictures of liver dysfunction and renal failure makes differentiation between the two diseases difficult . anaesthetic management for caesarean delivery in a parturient with malaria was previously reported without leptospiral co - infection . we report a case of a primigravida with falciparum malaria with altered mental status and leptospiral co - infection posted for emergency caesarean delivery , which was successfully managed both perioperatively and post - operatively . to the best of our knowledge , this is the first reported case of a patient of malaria - leptospira co - infection undergoing emergency caesarean delivery and intensive care management with intrapulmonary factor viia treatment . after obtaining written informed consent from the patient a 24-year - old primigravida , at 37 weeks of gestation was referred to our institute for further management on supplemental oxygen ( venturi mask ) after rapid test diagnosis of plasmodium falciparum ( pf ) malaria ( parasight-f , becton dickinson , sparks , md ) associated with acute icteric leptospirosis ( microscopic agglutination test ( mat ) titers for leptospira ictero - haemorrhagiae of 1:400 ) . her history revealed high grade fever , decreased urine output with yellowish discolouration and altered sensorium . she was disoriented , febrile and icteric and had sub - conjunctival haemorrhages and fine basal crepitations on auscultation . her pre - operative investigations in referral card revealed anaemia , jaundice with deranged liver function , coagulopathy , thrombocytopenia , increased total leucocyte count , elevated blood urea nitrogen and serum creatinine . abdominal ultrasonography showed a singleton pregnancy , adequate liquor , umbilical artery systolic - diastolic ratio of 2:1 and mild hepato - splenomegaly . within 1 h of arrival she was posted for emergency caesarean delivery because of non - reassuring fetal heart rate [ figure 1 ] . non reassuring fetal heart rate after administering aspiration prophylaxis and taking high - risk consent she was shifted to operation theatre . basic monitors were attached and rapid sequence intubation with cricoid pressure was carried out using thiopental and succinylcholine . right internal jugular vein and left radial artery were cannulated under ultrasonographic guidance simultaneously by two anaesthetists . anaesthesia was maintained with isoflurane in n2o - o2 mixture and atracurium until delivery of a 2.25 kg baby . neonatal data recorded were an apgar score of 6 and 8 at 1 and 5 min respectively , with cord blood ph of 7.28 , base deficit of 5.4 and blood sugar level of 50 mg / dl . blood loss was managed with packed red blood cells , fresh frozen plasma and platelets transfusion followed by noradrenaline infusion ( titrated doses ) . at the end of the surgery , she was shifted to intensive care unit ( icu ) in intubated state and on noradrenaline infusion . post - operative analgesia was maintained by ultrasound guided bilateral transverse abdominis plane block . in icu , on the second postoperative day , she developed pulmonary haemorrhage [ figure 2 ] . bed side fibre - optic bronchoscopy was carried out , which revealed erythematous mucosa , blood clots , active oozing and diffuse bleeding from distal airway . broncho alveolar lavage was performed and factor viia ( aryoseven , aryogen biopharma co , tehran , iran ) was administered ( 50 g / kg of rfviia in 50 ml distrilled water through the fibre - optic bronchoscope ( 25 ml in each main bronchus after lavage ) because of its thrombogenic effect . following this immediate bleeding cessation and significant reduction of inspired oxygen fraction ( fio2 ) was observed in the next 12 h. her chest radiograph , which showed bilateral non - homogeneous opacities ( lower and middle zones ) , the previous day became almost clear the next day . in view of acute kidney injury , severe hyperbilirubinemia and blood picture indicating haemolytic uremic syndrome ( high serum lactate dehydrogenase , schistocytes in peripheral blood ) , nephrology opinion was obtained and based on their suggestion , plasmapheresis followed by dialysis was done ( seven cycles each ) . because of the altered mental status , computed tomography of the brain was carried out , which showed diffuse cerebral oedema . for which cerebroprotective measures ( head elevation , not rotating neck , maintain serum sodium 145 - 155 meq / l , keeping blood partial pressure of carbondioxide 32 - 40 mmhg ) were undertaken . other investigations such as blood cultures , urine cultures , weil - felix test , typhi dot , dengue , and hepatitis viruses serology yielded negative results . supportive therapies like stress ulcer prevention , deep vein thrombosis prophylaxis ( pneumatic compression ) and glycemic control were provided . by the fourth post - operative day , the intensity of fever started reducing , consciousness improved , inotropic support tapered , urine output improved and liver function test with coagulation parameters showed improving trends . the prevalence and parasite density of pf is higher in primigravida , compared to multigravida or non - pregnant patients . infected erythrocytes aggregate , causing microcirculatory obstruction , thrombosis and local ischaemia , compromising cerebral , hepatic , renal , intestinal and pulmonary circulations leading to raised intracranial pressure ( icp ) , liver dysfunction , acute kidney injury , gastrointestinal bleeding and haemorrhagic pulmonary oedema . pfs placental sequestration reduces their standard smear visibility , producing false - negative results and therefore , rapid diagnostic tests are preferred . leptospirosis is common in low socioeconomic class with poor sanitation and hygiene and is under - diagnosed . in a patient with febrile illness with hepato - renal involvement malaria , leptospirosis , typhoid fever , viral hepatitis ( specially hepatitis e in pregnancy ) and scrub typhus . should be considered in the differential diagnosis . our decision to administer general anaesthesia was influenced by the presence of thrombocytopenia , coagulopathy , suspected raised icp , and impaired mental status . moreover , concerns of introducing malarial parasites into the cerebrospinal fluid , with regional anaesthesia exist . intraoperatively , thiopental and propofol are better suited in increased icp with cerebral malaria , whereas ketamine should be avoided . isoflurane in sub - mac concentration is appropriate as lesser cerebral vasodilatation causes less increase in icp . atracurium or cis - atracurium is the relaxants of choice in the presence of hepatic and renal dysfunction . endothelial clogging , vasospasm , microthrombosis , local ischaemia , and organ hypo - perfusion leads to lactic acidosis . hormonal imbalances because renal failure and fluid shift predisposing to fluid overload , which associated with parasite injured pulmonary capillaries can precipitate pulmonary oedema . anaemia occurs due to bone marrow depression , splenic uptake , erythrophagocytosis and autoimmune haemolysis . pregnancy itself causes thrombocytopenia , which further accentuates by platelet activation , splenic pooling and a decreased platelet life span ( 2 - 3 days ) . similar clinical features make a diagnosis of acute leptospirosis co - infection difficult and lead to delay in therapy initiation igm enzyme linked immunosorbent assay antibodies have more false positive results . a 21% higher mortality plasma exchange is an option in patients with severe icteric leptospirosis ( severe hyperbilirubinaemia ) complicated by renal failure who do not show rapid clinical response to conventional treatment . other than disseminated intravascular coagulation there are many off license use of fviia such as severe perioperative blood loss , traumatic massive bleeding and obstetric haemorrhage . we used it in our patient as pf leptospira infection with superimposed sepsis is associated with endothelial dysfunction and propensity for systemic vascular thrombosis ( venous and arterial ) and received favourable results . in conclusion , pf - leptospira co infection adversely affects the majority of the organ systems mainly through endothelial dysfunction . proper understanding of the pathophysiology helps anesthesiologist during the conduct of anaesthesia as well as icu management . intrapulmonary factor viia is a useful modality in pulmonary haemorrhage of malaria - leptospira co - infection .
malaria - leptospira co - infection is rarely detected . 
 emergency surgery in such patients has not been reported . 
 we describe such a case of a 24-year - old primigravida at term pregnancy posted for emergency caesarean delivery who developed pulmonary haemorrhage , acute respiratory distress syndrome , acute kidney injury , and cerebral oedema . here , we discuss the perioperative management , pain management ( with transverse abdominis plane block ) , intensive care management ( special reference to management of pulmonary haemorrhage with intra pulmonary factor viia ) and the role of plasmapheresis in leptospira related jaundice with renal failure .