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 Institute of Health and Medical Sciences (NEIGRIHMS) Shillong, Meghalaya.

Introduction: Malaria is a common disease with varied presenting features presenting features Presentation with common features: Not difficult to diagnose Unusual presentation may delay diagnosis and hence initiation of treatment.

Aims and objective To identify cases of malaria presenting with unusual features

Materials and method Study is carried out in Department of Pediatrics, NEIGRIHMS, Shillong. Study design: Retrospective case series Study period: 1 year ( Nov 2006 – Oct 2007) All the cases of malaria admitted to pediatric ICU or pediatric general ward were reviewed retrospectively

Results and Observations Total number of malaria cases: 49 Unusual presentation: 10 Median age of presentation: 10 yrs(1½ -17 yrs)

Unusual presentations PresentationNo. Age yrs Parasite Viral hepatitis like presentatrion 2 12, 17 Mixed Hyperglycemia2 17, 15 Mixed Focal deficit (hemiplegia) 2 6, 8 Mixed, Pf Acute abdomen 2 3, 4 Mixed Sever headache 116Clinical Sub acute intestinal obstruction 1 1 ½ P. vivax

Diagnosis Asexual stage of parasite in PBS: 9 Clinical: 1

Frequency of other features Three cases were afebrile at presentation But all cases had fever at some point of their illness

Viral hepatitis like presentation Case number History History Physical findings Laboratory features Case I 12 yrs Female Fever & vomiting: 5 days back Loss of appetite Afebrile on the day of presentation Pallor +,Icterus+ E4M5V3, Soft tender Hepatomegaly (18 cm span), No splenomegaly Hb- 7.3% TSB ( direct- 12.6), PT- 19” (Control - 13”) SGPT- 116 iu/L, SGOT- 270 iu/L Case II 17 yrs male Fever with 4 days, pain abdomen and vomiting Agitation and altered sensorium for 1 day. Pallor + icterus +, GCS 5/15 Echymosis +ve, G.I.bleed Tone increased, planter extensor B/L Spleen just palpable Hb- 9.5 gm% TSB- 9.2 (direct 6.6), SGOT 220iu/l,SGPT- 55 iu/l PT– ?? blood did not clot

Hemiplegia Both cases had no residual weakness at discharge. Case number history Physical findings Laboratory features Case 1 6 yrs F Fever 5 days Headache and altered sensorium 5 days Pallor, icterus +ve Hepatomegaly No splenomegaly GCS-12/ 15 Power 3/5 (L), 5/5 (R) Planter- extensor on L CSF- Normal study Case 2 8 yrs F Fever with altered sensorium – 6 days Pallor Pus in ® ear canal GCS- E4 M4V3 Power- 3/5 (L) 5/5 (R) Planter BL extensor CSF- Normal study CECT brain- NAD

Acute abdomen Both the children presented with Severe upper abdominal pain Severe upper abdominal pain High fever, Pallor, splenomegaly High fever, Pallor, splenomegaly Tenderness all over abdomen Tenderness all over abdomen PBS for MP +ve USG abdomen- normal study AXR: Normal

Hyperglycemia * RBS readings are by glucometer (lab verification done) Case No. History Physical findings Laboratory features Case 1 17 yrs F Altered sensorium FevercoughPallor GCS 10/15 Abdominal tenderness RBS at presentation- 131mg/dl RBS reading over 1st 48 hrs 131,101,149,HI,152,136, 170, 143 Case 2 15 yrs F Fever 2 wks Altered sensorium Seizure Severe pallor GCS E4V4M4 Compensated shock No hepatosplenomegaly At admission ‘HI’ RBS reading in first 24 hours HI, 512, 398,403, 309, 229,173,143,100 HI, 512, 398,403, 309, 229,173,143,100 Urine for ketone bodies negative

Blood sugar trend

Headache Intense headache- 4 days No history of fever, no seizure, no vomiting Low grade fever (up to F) in hospital CNS examination normal,Splenomegaly +ve Hb- 12 gm%, CT- solitary calcified lesion CSF- protein 135mg/dl, sugar 58 mg/dl (RBS 84) 7 cells- all lymphocytes. Response to Quinine within 48 hours

Sub-acute intestinal obstruction like presentation Abdominal distension- 1 week Fever off and on -4 days, associated with vomiting H/O of loose stool and vomiting 2 wks back On examination Afebrile Abdominal distension Hepatosplenomegaly Fever documented in hospital. Serum electrolytes - Normal PBS- P vivax Responded to Quinine

Discussion All presentations we described are uncommon yet known features of malaria. Children may present with prominent abdominal symptoms However acute abdomen like presentation may be misleading Sub acute intestinal obstruction like presentation may be confused with helminthiasis or septicemia or other surgical conditions. N J White: Malaria. In Manson’s text book of tropical medicine 21 st edition

Discussion contd.. WHO omitted jaundice as a case criteria for severe malaria. Bilirubin of > 10 is uncommon and hepatic failure is unusual. Malarial Hepatopathy emerging as a distinct entity, esp. in adolescent and adults. Falciparum malaria with jaundice with encephalopathy, is it cerebral malaria or hepatic encephalopathy?? N J White: Malaria. In Manson’s text book of tropical medicine 21 st edition Kochar D et al, Q J Med 2003 Anand AC Trop Gastroenterol SK satpathy et al Ind J pediatr 2004

Discussion contd.. Cerebral malaria is a global encephalopathy and focal signs are uncommon. However, various focal neurological deficits including hemiplegia, hemianopia and cranial nerve palsies have been described Hypoglycemia is found in up to 30% pediatric severe malaria There are only few reports of Hyperglycemia Mechanism may be analogous to hyperglycemia in critical patients. N J White: Malaria. In Manson’s text book of tropical medicine 21 st edition

Discussion contd.. Headache is a common feature of malaria. However a prominent headache in absence of history of fever is confusing.

Conclusion Our experience shows that malaria may present with atypical manifestations which may mimic other medical and surgical illnesses. A high index of suspicion is therefore needed in managing all cases of fever at some point of their illness, especially in endemic areas so that diagnosis and treatment is not delayed.