162 Geliş Tarihi/Received: 20/10/2014 - Kabul Ediliş Tarihi/Accepted: 16/11/2014
OLGU SUNUMU
/
CASE REPORT
flora
FLORA 2015;20(3):162-165
An Unusual Presentation of Falciparum Malaria
As a Cause of Anemia
Bir Anemi Nedeni Olarak Alışılmışın Dışında Bir Falsiparum Sıtma Olgusu
İlkay BOZKURT1, Hava YILMAZ1, Heval BİLEK1, Mustafa SÜNBÜL11 Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, University of Ondokuz Mayis, Samsun, Turkey
SUMMARY
Malaria is a serious disease and may sometimes be fatal. The disease is seen in countries with tropical and subtropical climates. We report a clinical case of malaria from our country where only imported malaria cases are reported, but where the disease still continues to be a problem. Hepatosplenomegaly was the only positive physical examination fi nding of the 49-year-old male patient who had no any other symptom except for fatigue and palpitation. Hemoglobin level of the patient was 5.4 g/dL. He was admitted to the hospital for the investigation of the cause of anemia. It was found that he had recently arrived from Nigeria and got malaria, and therefore, treated about a month ago. Up on the visualisation of rounded trophozoites with ring forms and gametocytes in the stained blood smears of the patient, the patient was diagnosed with malaria and treated for it.
Key Words: Plasmodium falciparum; Malaria; Anemia
ÖZET
Bir Anemi Nedeni Olarak Alışılmışın Dışında Bir Falsiparum Sıtma Olgusu
İlkay BOZKURT1, Hava YILMAZ1, Heval BİLEK1, Mustafa SÜNBÜL1
1 Ondokuz Mayıs Üniversitesi Tıp Fakültesi, İnfeksiyon Hastalıkları ve Klinik Mikrobiyoloji Anabilim Dalı, Samsun, Türkiye
Sıtma bazen ölümcül olabilen ciddi bir hastalıktır. Tropikal veya tropikal iklime yakın bölgelerde görülür. Sadece yurtdışı kaynaklı sıtma olgularının görüldüğü ancak hastalığın sorun olmaya devam ettiği ülkemizden klinik bir olgu sunulmuştur. Halsizlik ve çarpıntı dışında şikayeti, hepatosplenomegali dışında pozitif muayene bulgusu olmayan 49 yaşındaki erkek hastanın hemoglobini 5.4 g/dL idi. Anemi nedeni araştırılmak üzere yatırılan hastanın Nijerya’dan yeni geldiği, yaklaşık bir ay önce sıtma geçirdiği ve bu yüzden tedavi aldığı öğrenildi. Hastanın periferik yayması incelendi. Taşlı yüzük şeklinde trofozoit formlarının ve gametositlerin görülmesi üzerine hasta sıtma olarak değerlendirildi ve tedavi edildi.
Bozkurt İ, Yılmaz H, Bilek H, Sünbül M.
163
FLORA 2015;20(3):162-165
INTRODUCTION
Malaria is still a devastating parasitic disease in tropical developing countries. It is estimated that 250 to 500 million febrile illnesses and up to a million deaths occur annually[1]. The disease may present with atypical presentations so the diagnosis becomes confusing, and thus, the delay in treatment may cause various complications[2]. Despite intensive efforts over the last century to control malaria, it remains a leading cause of morbidity and mortality in humans[3].
Herein, we aimed to report a case of
Plasmodium falciparum malaria manifested as
severe anemia in a returning traveller from an endemic area in Nigeria.
CASE REPORT
A 49-year-old male mechanical engineer with no underlying diseases or medications was in Nigeria between January and July, 2014. During his stay, he had not regularly taken antimalarial chemoprophylaxis or any personal protection measures. On the June 1st, 2014, he had been hospitalized in a private clinic in Nigeria with preliminary diagnosis of malaria and diarrhea. According to the medical report, he had presented with the symptoms of altered mental status, fever, diarrheae, generalized body weakness, and jaundice. Malaria parasite had been observed in peripheral smear of the patient. Biochemical tests had been performed and revealed in normal range except elevated ALT, AST and bilirubin levels. He had been managed on artemether, ciprofloxacin and metronidazole and also rehydrated for five days. When his general clinical condition had improved as evidenced by resolving jaundice, subsided fever, improved appetite consciousness and cessation of diarrhea, he was discharged at the end of the therapy. He returned to Turkey on June 6th, 2014. He was referred to the emergency clinic of Ondokuz Mayis University Hospital with symptoms of malaise and tachycardia. Laboratory examination showed hemoglobin level of 5.4 g/dL. Eriythrocyte suspension replacement therapy was administered during the follow up in the emergency clinic. He had no fever but he was consulted by infectious diseases due to his travel history to a malaria endemic area. On admission, he had afebrile,
blood pressure of 100/60 mmHg, and pulse of 94 beats per minute. Physical examination revealed hepatosplenomegaly. His vital signs were stable. An initial blood test revealed anemia (5.4 g/dL; normal range 13.3 to 17.2 g/dL). All other blood test results were in normal range. We examined thin and thick Giemsa stained blood smears and observed rounded compact young trophozoites with ring forms and gametocytes (Figure 1). We applied arthemeter lumefantrine plus doxycycline treatment. On the third day of therapy, fever occurred and resolved in 48 hours. He was discharged on the 7th day of therapy, and three weeks later, during the outpatient clinic control, hepatosplenomegaly was resolved and anemia improved completely.
DISCUSSION
Malaria is an ongoing health problem particularly for developing countries in tropical regions[4]. It is estimated that 40% of the world population have been affected by this illness[5]. Turkey, Azerbaijan and Tajikistan are all placed among countries which are in malaria elimination phase[3]. By the support of the World Health Organisation (WHO) Malaria Elimination Programme the number of local malaria cases have recently decreased; however, imported malaria is increasing especially via occupational travelling. According to the Ministry of Health in Turkey 376 malaria cases were reported in 2012. Out of the 376 cases, 375 were imported and introduced cases and one was relapsing case of vivax malaria[3,6].
Figure 1. Peripheral smear of the patient with falciparum
malaria shows double intraerythrocytic ring forms of trophozoites and gametocyte.
An Unusual Presentation of Falciparum Malaria As a Cause of Anemia
164 FLORA 2015;20(3):162-165
The clinical manifestations of malaria depend on the geography, epidemiology, immunity, and age[4]. Travellers to malarious areas have had no history of malaria exposure or have already lost their immunity when they left endemic places. If infected with P. falciparum, they would be at high risk for severe malaria[7-9]. In highly endemic areas, partial immunity develops particularly in adults after repeated infections throughout the year, causing less severe illnesses[10]. All of these different clinical situations occured in the patient presented here. Firstly, he had severe symptoms in Nigeria because of deficiency of immunity against malaria although he had been in this highly endemic area for the last six months. Afterwards, when he returned to Turkey, he just complained about malaise. He presented nearly one month later with nonspecific symptoms like malaise and tachicardia since probably he had partial immunity due to inadequate therapy. Therefore, this may have caused this clinical course without fever. Imported malaria cases may be presented as recrudescence in uncomplicated cases as well as severe symptoms[11]. In the literature, data on malaria have been presented from different centres. Recently, only imported malaria cases have been reported in our country[12-14]. According to a research from Manisa, 86955 blood samples were evaluated between 2008 and 2012 and 6 (0.007%) cases were detected and all were imported like the case presented here[15]. Falciparum malaria is the most important illness that incurs not working and sometimes death for people particularly living or working in high risk malarious areas[16]. It is a common imported infection and may be presented with atypical features. For this reason, it shoud be considered in all febrile and also afebrile patients with travel history to malarious areas.
Travellers should be informed about antimalarial drug safety and also efficacy and continue to use malaria chemoprophylaxis during the entire stay[7]. We recommended doxycycline to this patient for long term occupational travels in endemic areas since doxycycline is well-tolerated for long-term malaria chemoprophylaxis and CDC has no recommended limits on its duration of use for malaria chemoprophylaxis. Mefloquine, atovaquone-proguanil, primaquine, chloroquine
are been well-tolerated during prolonged stays[7]. Antimalarial drugs can be provided free by the Directorate General of Health for Border and Coastal Areas, Travel Health Center of Ministry of Health in our country.
As a conclusion, when a patient is presented with the history of traveling to or staying in malaria endemic coutries, it should be considered that the disease may be presented without fever and blood smears should be performed to rule out malaria.
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Yazışma Adresi/Address for Correspondence
Yrd. Doç. Dr. İlkay BOZKURT Erciyes Üniversitesi Tıp Fakültesi İnfeksiyon Hastalıkları ve Klinik Mikrobiyoloji Anabilim Dalı Samsun-Türkiye
