Indian J Pediatr DOI 10.1007/s12098-014-1520-6
SCIENTIFIC LETTER
Cerebral Malaria due to Plasmodium vivax in a Young Infant Mritunjay Kumar & Shruti Kumar & Bindu Agrawal & Rashmi Kumari
Received: 22 December 2013 / Accepted: 12 June 2014 # Dr. K C Chaudhuri Foundation 2014
To the Editor: Plasmodium vivax has been found to be associated with all the sequestration and non-sequestration related complications of severe malaria, including cerebral malaria [1]. In malaria endemic zone, infants less than 3 mo of age have been found to be relatively immune to Plasmodium falciparum malaria but effect of Plasmodium vivax in this age group is little known [2]. A two-mo-old girl (from malaria endemic zone) weighing 4.4 kg, presented with 4 d history of high grade fever, convulsions and loss of consciousness. There was no history of fever or blood transfusion in mother during antenatal period. The infant had no previous hospitalization, blood transfusion or exchange transfusion. At admission she was unconscious with Blantyre coma scale of 2. She had pallor, axillary temperature of 102 °F, heart rate of 170/min, respiratory rate of 50/min and blood pressure of 96/50 mm of Hg. Abdominal examination revealed hepatomegaly (4 cm below right costal margin). She had hypertonia and extensor plantar response. Rest of the systemic examination was unremarkable. Intravenous antibiotics and multiple antiepileptics were given for which she required elective mechanical ventilation. Investigations revealed hemoglobin 9.9 g/dl, total leukocyte count 11,000 cells/mm3 (40 % polymorphs and 55 % lymphocytes) and platelet count 1.7 lac/mm3. Three consecutive peripheral blood smear examination were positive for Plasmodium vivax and negative for Plasmodium falciparum which was reconfirmed by positive rapid antigen test (HRP-II and pLDH with 99 % specificity) for Plasmodium vivax. Cerebrospinal
fluid examination, CT scan of head and other biochemical investigations were normal. Intravenous artesunate was started and within 48 h she became afebrile and conscious. She was gradually weaned off ventilator and antiepileptics. Repeat peripheral blood smear examination at 48 h was negative for Plasmodium vivax. After 7 d course of artesunate, patient was discharged on oral phenytoin in a clinically stable condition with no neurological deficit. Primaquin was not given as recommended by National Drug Policy on malaria [3]. At 4 wk follow up, she was asymptomatic with no neurological abnormality and hence, phenytoin was stopped. Infants younger than 3 mo have a lower than expected incidence of parasitemia, clinical disease, and death from malaria. The two most important causes for it are probably the fact that level of serological immunity is high at this stage and that fetal hemoglobin (HbF) is present in circulating red blood cells [4]. Cerebral dysfunction in Plasmodium vivax malaria may occur through generation of nitric oxide [5]. Severe vivax malaria is an emerging recognized entity and hence, it is important to look for vivax malaria even in the youngest of patients with suspected CNS infection.
M. Kumar (*) : S. Kumar : B. Agrawal Department of Pediatrics, SGRR Institute of Medical and Health Sciences, Patel Nagar, Dehradun 248001, Uttarakhand, India e-mail: [email protected]
1. Kochar DK, Saxena V, Singh N, Kochar SK, Kumar SV, Das A. Plasmodium vivax malaria. Emerg Infect Dis. 2005;11. http:// wwwnc.cdc.gov/eid/article/11/1/04-0519.htm 2005 Jan. Accessed on 20th October 2013. 2. Poespoprodjo JR, Fobia W, Kenangalem E, Lampah DA, Hasanuddin A, Warikar N, et al. Vivax malaria: a major cause of morbidity in early infancy. Clin Infect Dis. 2009;48:1704–12. 3. National drug policy on malaria. 2013. http://www.nvbdcp.gov.in/ Doc/National-Drug-Policy-2013.pdf. Accessed on 18th April, 2014.
R. Kumari Department of Community Medicine, SGRR Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India
Conflict of Interest None. Source of Funding None.
References
Indian J Pediatr 4. Maldonado YA. Less common protozoan and helminth infections. In: Remington JS, Klein JO, Wilson CB, Nizet V, Maldonado YA, editors. Infectious diseases of the fetus and newborn infant. 7th ed. USA: Saunders; 2011. p. 1048.
5. Kochar DK, Das A, Kochar SK, Saxena V, Sirohi P, Garg S, et al. Severe Plasmodium vivax malaria: a report on serial cases from Bikaner in northwestern India. Am J Trop Med Hyg. 2009;80:194–8.
SCIENTIFIC LETTER
Cerebral Malaria due to Plasmodium vivax in a Young Infant Mritunjay Kumar & Shruti Kumar & Bindu Agrawal & Rashmi Kumari
Received: 22 December 2013 / Accepted: 12 June 2014 # Dr. K C Chaudhuri Foundation 2014
To the Editor: Plasmodium vivax has been found to be associated with all the sequestration and non-sequestration related complications of severe malaria, including cerebral malaria [1]. In malaria endemic zone, infants less than 3 mo of age have been found to be relatively immune to Plasmodium falciparum malaria but effect of Plasmodium vivax in this age group is little known [2]. A two-mo-old girl (from malaria endemic zone) weighing 4.4 kg, presented with 4 d history of high grade fever, convulsions and loss of consciousness. There was no history of fever or blood transfusion in mother during antenatal period. The infant had no previous hospitalization, blood transfusion or exchange transfusion. At admission she was unconscious with Blantyre coma scale of 2. She had pallor, axillary temperature of 102 °F, heart rate of 170/min, respiratory rate of 50/min and blood pressure of 96/50 mm of Hg. Abdominal examination revealed hepatomegaly (4 cm below right costal margin). She had hypertonia and extensor plantar response. Rest of the systemic examination was unremarkable. Intravenous antibiotics and multiple antiepileptics were given for which she required elective mechanical ventilation. Investigations revealed hemoglobin 9.9 g/dl, total leukocyte count 11,000 cells/mm3 (40 % polymorphs and 55 % lymphocytes) and platelet count 1.7 lac/mm3. Three consecutive peripheral blood smear examination were positive for Plasmodium vivax and negative for Plasmodium falciparum which was reconfirmed by positive rapid antigen test (HRP-II and pLDH with 99 % specificity) for Plasmodium vivax. Cerebrospinal
fluid examination, CT scan of head and other biochemical investigations were normal. Intravenous artesunate was started and within 48 h she became afebrile and conscious. She was gradually weaned off ventilator and antiepileptics. Repeat peripheral blood smear examination at 48 h was negative for Plasmodium vivax. After 7 d course of artesunate, patient was discharged on oral phenytoin in a clinically stable condition with no neurological deficit. Primaquin was not given as recommended by National Drug Policy on malaria [3]. At 4 wk follow up, she was asymptomatic with no neurological abnormality and hence, phenytoin was stopped. Infants younger than 3 mo have a lower than expected incidence of parasitemia, clinical disease, and death from malaria. The two most important causes for it are probably the fact that level of serological immunity is high at this stage and that fetal hemoglobin (HbF) is present in circulating red blood cells [4]. Cerebral dysfunction in Plasmodium vivax malaria may occur through generation of nitric oxide [5]. Severe vivax malaria is an emerging recognized entity and hence, it is important to look for vivax malaria even in the youngest of patients with suspected CNS infection.
M. Kumar (*) : S. Kumar : B. Agrawal Department of Pediatrics, SGRR Institute of Medical and Health Sciences, Patel Nagar, Dehradun 248001, Uttarakhand, India e-mail: [email protected]
1. Kochar DK, Saxena V, Singh N, Kochar SK, Kumar SV, Das A. Plasmodium vivax malaria. Emerg Infect Dis. 2005;11. http:// wwwnc.cdc.gov/eid/article/11/1/04-0519.htm 2005 Jan. Accessed on 20th October 2013. 2. Poespoprodjo JR, Fobia W, Kenangalem E, Lampah DA, Hasanuddin A, Warikar N, et al. Vivax malaria: a major cause of morbidity in early infancy. Clin Infect Dis. 2009;48:1704–12. 3. National drug policy on malaria. 2013. http://www.nvbdcp.gov.in/ Doc/National-Drug-Policy-2013.pdf. Accessed on 18th April, 2014.
R. Kumari Department of Community Medicine, SGRR Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India
Conflict of Interest None. Source of Funding None.
References
Indian J Pediatr 4. Maldonado YA. Less common protozoan and helminth infections. In: Remington JS, Klein JO, Wilson CB, Nizet V, Maldonado YA, editors. Infectious diseases of the fetus and newborn infant. 7th ed. USA: Saunders; 2011. p. 1048.
5. Kochar DK, Das A, Kochar SK, Saxena V, Sirohi P, Garg S, et al. Severe Plasmodium vivax malaria: a report on serial cases from Bikaner in northwestern India. Am J Trop Med Hyg. 2009;80:194–8.
