Dr.Akshay Kishore , Dr.Krishna Kumar , Dr.Praveena N Bhaskaran , Dr.C.Jayakumar , AIMS kochi.
Eight year old female child Ugandan child Ugandan citizen diagnosed case of , case of rheumatic heart disease with severe MR planned for mitral valve repair presented with grade fever with chills and rigors for 1 week duration.
Pointer symptoms suggestive of involvement of other system was not present
Differential diagnosis considered were
1.Malaria infection
2.Deep seated abscess.
3Urinary infection
4.Pneumonia
5 Infective endocarditis
On examination , she was febrile
Other PICCLE findings were normal
CVS examination
Apex showed hyper-dynamic precordium with pan systolic murmur grade 3/6. in the mitral area radiating to the axilla
GIT examination showed hepatomegaly 2cm below right coastal margin and splenomegaly.
Investigations revealed normal counts with mildly elevated CRP – 19.53. Serum Creat was elevated 0.94 mg/dl with normal LFT.
Urine exam was normal.
Chest Xray cardiac enlargement
Echo done showed severe MR with no significant submitral valve pathology.
Dilated LA/LV with normal LV systolic function.
Dengue IgM was positive with positive falciparum malaria.
Malaria antigen was positive for plasmodium falciparum.
Thick smear was positive for falciparum malaria with rings and schizontz.
USG abdomen showed bilateral echogenic kidneys with maintained corticomedullary differentiation.
She was started on Artemisinin combination therapy. She responded well to treatment.
Discussion :
Malaria is caused intracellular Plasmodium protozoa transmitted to humans female Anopheles mosquito.
Uncomplicated falciparum malaria consists of symptomatic Plasmodium falciparum infection with a positive parasitologic test and parasitemia <4 percent, in the absence of symptoms consistent with severe malaria. They can present with fever , convulsions , renal impairment , jaundice , anemia and splenomegaly.
Classic ring-shaped/headphone-shaped trophozoites are seen in case of Plasmodium falciparum infection. Cerebral malaria is a complicated form of malaria which is most commonly associated with P. falciparum infection. Both thick and thin blood smears should be examined. The concentration of erythrocytes on a thick smear is 20-40 times that on a thin smear and is used to quickly scan large numbers of erythrocytes. The thin smear allows for positive identification of the malaria species and determination of the percentage of infected erythrocytes and is useful in following the response to therapy. The BinaxNOW Malaria test is approved the U.S. Food and Drug Administration (FDA) for rapid diagnosis of malaria. This immunochromatographic test for P. falciparum histidine-rich protein (HRP2) and aldolase is approved for testing for P. falciparum and P. vivax. Cerebral malaria is a dreaded complication and is a medical emergency. Treatment of falciparum malaria include Artemisinin combination therapy which include Artemether-lumefantrine, Artesunate-amodiaquine, Artesunate-mefloquine , Artesunate-pyronaridine.
The total artemisinin dose (10 to 12 mg/kg) is given over three days. In areas of artemisinin resistance, a six-day course of treatment is warranted.
Take home message : Prompt treatment reduces the risk of complications especially cerebral malaria.