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.

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.