Unusual presentations of malaria: Our experience P Jain, R Dass, A Chhetri, H Barman, D J Sharma, B Saikia, S G Duarah North Eastern Indira Gandhi Regional.
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Unusual presentations of Unusual presentations of malaria: Our experiencemalaria: Our experience
P Jain, R Dass, A Chhetri , H Barman, P Jain, R Dass, A Chhetri , H Barman,
D J Sharma, B Saikia, S G DuarahD J Sharma, B Saikia, S G Duarah
North Eastern Indira Gandhi Regional Institute of Health and Medical North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS)Sciences (NEIGRIHMS)
Shillong, Meghalaya.Shillong, Meghalaya.
Introduction:Introduction:
Malaria is a common disease with variedMalaria is a common disease with varied
presenting featurespresenting features
Presentation with common features: Not Presentation with common features: Not difficult to diagnosedifficult to diagnose
Unusual presentation may delay diagnosis Unusual presentation may delay diagnosis and hence initiation of treatment.and hence initiation of treatment.
Aims and objectiveAims and objective
To identify cases of malaria presenting To identify cases of malaria presenting with unusual featureswith unusual features
Materials and methodMaterials and method
Study is carried out in Department of Study is carried out in Department of Pediatrics, NEIGRIHMS, Shillong.Pediatrics, NEIGRIHMS, Shillong.
Study design: Retrospective case seriesStudy design: Retrospective case series
Study period: 1 year (Study period: 1 year (Nov 2006 – Oct 2007)Nov 2006 – Oct 2007)
All the cases of malaria admitted to All the cases of malaria admitted to pediatric ICU or pediatric general ward pediatric ICU or pediatric general ward were reviewed retrospectivelywere reviewed retrospectively
Results and ObservationsResults and Observations
Total number of malaria cases: 49Total number of malaria cases: 49
Unusual presentation: 10Unusual presentation: 10
Median age of presentation: 10 yrs(1½ -17 yrs)Median age of presentation: 10 yrs(1½ -17 yrs)
unusual presentatio
ns20%
Unusual presentationsUnusual presentations
PresentationPresentation No. No. Age Age yrsyrs
ParasiteParasite
Viral hepatitis like presentatrionViral hepatitis like presentatrion 22 12, 1712, 17 MixedMixed
HyperglycemiaHyperglycemia 22 17, 1517, 15 Mixed Mixed
Focal deficit (hemiplegia)Focal deficit (hemiplegia) 22 6, 86, 8 Mixed, Pf Mixed, Pf
Acute abdomen Acute abdomen 22 3, 43, 4 Mixed Mixed
Sever headacheSever headache 11 1616 ClinicalClinical
Sub acute intestinal obstructionSub acute intestinal obstruction 11 1 ½ 1 ½ P. vivaxP. vivax
Diagnosis Diagnosis
Asexual stage of parasite in PBS: 9 Asexual stage of parasite in PBS: 9
Clinical: 1Clinical: 1
mode of diagnosis and affecting parasite
clinical 1pf 1
pv 1
mixed 6
Frequency of other features Frequency of other features
1
2
3
5
4
5
5
7
0 2 4 6 8 10
spont. bleeding
hyper parasitemia
jaundice
splenomegaly
pain abdomen
vomiting
CNS Symptoms
fever at presentation
•Three cases were afebrile at presentation• But all cases had fever at some point of their illness
Viral hepatitis like presentationViral hepatitis like presentationCase Case numbernumber
HistoryHistory Physical Physical findingsfindings
Laboratory featuresLaboratory features
Case ICase I
12 yrs12 yrs
FemaleFemale
FeverFever & & vomiting:vomiting: 5 5 days backdays back
Loss of appetiteLoss of appetite
Afebrile on the day Afebrile on the day of presentationof presentation
Pallor +,Pallor +,Icterus+Icterus+
E4M5V3, E4M5V3,
Soft tender Soft tender HepatomegalyHepatomegaly (18 (18 cm span),cm span),
No splenomegalyNo splenomegaly
Hb- 7.3% Hb- 7.3%
TSB- 17.3 ( direct- 12.6),TSB- 17.3 ( direct- 12.6),
PT- 19PT- 19” (Control - 13”) ” (Control - 13”)
SGPT- 116 iu/L, SGOT- 270 SGPT- 116 iu/L, SGOT- 270 iu/Liu/L
Case IICase II
17 yrs17 yrs
malemale
FeverFever with 4 days, with 4 days, pain abdomenpain abdomen and and vomitingvomiting
AgitationAgitation and and altered sensorium for altered sensorium for 1 day.1 day.
Pallor + Pallor + icterus +,icterus +, GCS 5/15GCS 5/15
Echymosis +veEchymosis +ve, , G.I.bleed G.I.bleed Tone increased, Tone increased, planter extensor B/Lplanter extensor B/L
Spleen just Spleen just palpablepalpable
Hb- 9.5 gm%Hb- 9.5 gm%
TSB- 9.2 (direct 6.6TSB- 9.2 (direct 6.6), ),
SGOT 220iu/l,SGPT- 55 iu/lSGOT 220iu/l,SGPT- 55 iu/l
PT– ?? blood did not clotPT– ?? blood did not clot
HemiplegiaHemiplegiaBoth cases had no residual weakness at discharge.Both cases had no residual weakness at discharge.
Case Case numbernumber
historyhistory Physical findingsPhysical findings Laboratory Laboratory featuresfeatures
Case 1Case 1
6 yrs F6 yrs F
Fever 5 daysFever 5 days
Headache and Headache and altered sensorium 5 altered sensorium 5 daysdays
Pallor, Pallor, icterus +veicterus +ve
HepatomegalyHepatomegaly
No splenomegalyNo splenomegaly
GCS-12/ 15GCS-12/ 15
Power 3/5 (L), 5/5 (R)Power 3/5 (L), 5/5 (R)
Planter- extensor on Planter- extensor on LL
CSF- Normal studyCSF- Normal study
Case 2Case 2
8 yrs F8 yrs F
Fever with altered Fever with altered sensorium – 6 dayssensorium – 6 days
PallorPallor
Pus in ® ear canalPus in ® ear canal
GCS- E4 M4V3GCS- E4 M4V3
Power- 3/5 (L) 5/5 (R)Power- 3/5 (L) 5/5 (R)
Planter BL extensorPlanter BL extensor
CSF- Normal studyCSF- Normal study
CECT brain- NADCECT brain- NAD
Acute abdomenAcute abdomen
Both the children presented withBoth the children presented with Severe upper abdominal painSevere upper abdominal pain High fever, Pallor, splenomegalyHigh fever, Pallor, splenomegaly Tenderness all over abdomenTenderness all over abdomen
PBS for MP +vePBS for MP +ve
USG abdomen- normal studyUSG abdomen- normal study
AXR: NormalAXR: Normal
HyperglycemiaHyperglycemia
* RBS readings are by glucometer (lab verification done)* RBS readings are by glucometer (lab verification done)
Case No.Case No. HistoryHistory Physical findingsPhysical findings Laboratory featuresLaboratory features
Case 1Case 1
17 yrs F17 yrs F
Altered sensoriumAltered sensorium
FeverFever
coughcough
PallorPallor
GCS 10/15GCS 10/15
Abdominal Abdominal tendernesstenderness
RBS at presentation- RBS at presentation- 131mg/dl131mg/dl
RBS reading over 1st 48 RBS reading over 1st 48 hrshrs
131,101,149,HI,152,136,1131,101,149,HI,152,136,170, 14370, 143
Case 2Case 2
15 yrs F15 yrs F
Fever 2 wksFever 2 wks
Altered sensoriumAltered sensorium
SeizureSeizure
Severe pallorSevere pallor
GCS E4V4M4GCS E4V4M4
Compensated shockCompensated shock
No No hepatosplenomegalyhepatosplenomegaly
At admission ‘HI’At admission ‘HI’
RBS reading in first 24 RBS reading in first 24 hourshours
HI, 512, 398,403, 309, HI, 512, 398,403, 309, 229,173,143,100229,173,143,100
Urine for ketone bodies Urine for ketone bodies negativenegative
Blood sugar trend Blood sugar trend
0
100
200
300
400
500
600
adm
ission
4 hr
s8h
rs
16 h
rs
18 h
rs
22 h
rs 26 30 34 38 42 46
case 2
case 1
Headache Headache
Intense headache- 4 daysIntense headache- 4 daysNo history of fever, no seizure, no vomitingNo history of fever, no seizure, no vomitingLow grade fever (up to 101.4 F) in hospitalLow grade fever (up to 101.4 F) in hospitalCNS examination normal ,Splenomegaly +veCNS examination normal ,Splenomegaly +veHb- 12 gm%,Hb- 12 gm%,CT- solitary calcified lesionCT- solitary calcified lesionCSF- protein 135mg/dl, sugar 58 mg/dl CSF- protein 135mg/dl, sugar 58 mg/dl (RBS 84) 7 cells- all lymphocytes.(RBS 84) 7 cells- all lymphocytes.Response to Quinine within 48 hoursResponse to Quinine within 48 hours
Sub-acute intestinal obstruction like Sub-acute intestinal obstruction like presentationpresentation
Abdominal distension- 1 weekAbdominal distension- 1 weekFever off and on -4 days, associated with vomitingFever off and on -4 days, associated with vomitingH/O of loose stool and vomiting 2 wks backH/O of loose stool and vomiting 2 wks backOn examinationOn examination
AfebrileAfebrileAbdominal distensionAbdominal distensionHepatosplenomegalyHepatosplenomegaly
Fever documented in hospital.Fever documented in hospital.Serum electrolytes - NormalSerum electrolytes - NormalPBS- P vivaxPBS- P vivaxResponded to QuinineResponded to Quinine
DiscussionDiscussionAll presentations we described are uncommon yet All presentations we described are uncommon yet known features of malaria.known features of malaria.
Children may present with prominent abdominal Children may present with prominent abdominal symptomssymptoms
However acute abdomen like presentation may be However acute abdomen like presentation may be misleadingmisleading
Sub acute intestinal obstruction like presentation Sub acute intestinal obstruction like presentation may be confused with helminthiasis or septicemia may be confused with helminthiasis or septicemia or other surgical conditions.or other surgical conditions.
N J White: Malaria. In Manson’s text book of tropical medicine 21N J White: Malaria. In Manson’s text book of tropical medicine 21stst edition edition
Discussion contd..Discussion contd..WHO omitted jaundice as a case criteria for WHO omitted jaundice as a case criteria for severe malaria.severe malaria.
Bilirubin of > 10 is uncommon and hepatic Bilirubin of > 10 is uncommon and hepatic failure is unusual.failure is unusual.
Malarial Hepatopathy emerging as a distinct Malarial Hepatopathy emerging as a distinct entity, esp. in adolescent and adults.entity, esp. in adolescent and adults.
Falciparum malaria with jaundice with Falciparum malaria with jaundice with encephalopathy, is it cerebral malaria or encephalopathy, is it cerebral malaria or hepatic encephalopathy??hepatic encephalopathy??
N J White: Malaria. In Manson’s text book of tropical medicine 21N J White: Malaria. In Manson’s text book of tropical medicine 21stst edition editionKochar D et al, Q J Med 2003Kochar D et al, Q J Med 2003Anand AC Trop Gastroenterol. 2001Anand AC Trop Gastroenterol. 2001SK satpathy et al Ind J pediatr 2004SK satpathy et al Ind J pediatr 2004
Discussion contd..Discussion contd..Cerebral malaria is a global encephalopathy Cerebral malaria is a global encephalopathy and focal signs are uncommon.and focal signs are uncommon.However, various focal neurological deficits However, various focal neurological deficits including hemiplegia, hemianopia and cranial including hemiplegia, hemianopia and cranial nerve palsies have been described nerve palsies have been described Hypoglycemia is found in up to 30% pediatric Hypoglycemia is found in up to 30% pediatric severe malariasevere malariaThere are only few reports of HyperglycemiaThere are only few reports of HyperglycemiaMechanism may be analogous to hyperglycemia Mechanism may be analogous to hyperglycemia in critical patients.in critical patients.
N J White: Malaria. In Manson’s text book of tropical medicine 21N J White: Malaria. In Manson’s text book of tropical medicine 21stst edition edition
Discussion contd..Discussion contd..
Headache is a common feature of malaria.Headache is a common feature of malaria.
However a prominent headache in However a prominent headache in absence of history of fever is confusing.absence of history of fever is confusing.
Conclusion Conclusion
Our experience shows that malaria may Our experience shows that malaria may present with atypical manifestations which present with atypical manifestations which may mimic other medical and surgical may mimic other medical and surgical illnesses. illnesses. A high index of suspicion is therefore A high index of suspicion is therefore needed in managing all cases of fever at needed in managing all cases of fever at some point of their illness, especially in some point of their illness, especially in endemic areas so that diagnosis and endemic areas so that diagnosis and treatment is not delayed.treatment is not delayed.
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