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Unusual presentations of malaria: Our experience

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

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Unusual presentations of malaria: Our experience

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  1. 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.

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

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

  4. 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

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

  6. Unusual presentations

  7. Diagnosis • Asexual stage of parasite in PBS: 9 • Clinical: 1

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

  9. Viral hepatitis like presentation

  10. Hemiplegia • Both cases had no residual weakness at discharge.

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

  12. Hyperglycemia* RBS readings are by glucometer (lab verification done)

  13. Blood sugar trend

  14. Headache • Intense headache- 4 days • No history of fever, no seizure, no vomiting • Low grade fever (up to 101.4 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

  15. 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

  16. 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 21st edition

  17. 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 21st edition • Kochar D et al, Q J Med 2003 • Anand AC Trop Gastroenterol. 2001 • SK satpathy et al Ind J pediatr 2004

  18. 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 21st edition

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

  20. 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.

  21. Thank you

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