|Year : 2014 | Volume
| Issue : 2 | Page : 107-108
Simultaneous presentation of Plasmodium vivax malaria in two siblings following visit to an endemic area: An uncommon presentation
Thirunavukkarasu A Babu, Vijayasankar V Devagaran
Department of Pediatrics, Indira Gandhi Medical College and Research Institute, Puducherry, India
|Date of Web Publication||18-Aug-2014|
Dr. Thirunavukkarasu A Babu
Department of Pediatrics, Indira Gandhi Medical College and Research Institute, Puducherry - 605 010
Source of Support: None, Conflict of Interest: None
Plasmodium vivax usually causes a benign illness in children, but a recent change in virulence has led to a drastic change in clinical spectrum. Falciparum malaria has been reported to present in family members simultaneously, but no such reports are documented for vivax malaria in the literature. The authors report two cases of P. vivax malaria presenting simultaneously in children belonging to the same family following visit to an endemic area.
Keywords: Children, endemic, falciparum, Plasmodium vivax, siblings
|How to cite this article:|
Babu TA, Devagaran VV. Simultaneous presentation of Plasmodium vivax malaria in two siblings following visit to an endemic area: An uncommon presentation. J Med Trop 2014;16:107-8
|How to cite this URL:|
Babu TA, Devagaran VV. Simultaneous presentation of Plasmodium vivax malaria in two siblings following visit to an endemic area: An uncommon presentation. J Med Trop [serial online] 2014 [cited 2021 May 10];16:107-8. Available from: https://www.jmedtropics.org/text.asp?2014/16/2/107/139067
| Introduction|| |
Despite substantial advances in the understanding of pathophysiology and clinical spectrum of malaria, it is still one of the leading causes of morbidity due to febrile illness in children from tropical countries.  Unlike malaria due to Plasmodium falciparum, Plasmodium vivax usually causes a benign illness, but a recent change in virulence has led to a drastic change in clinical spectrum. 
There are few reports of P. falciparum malaria occurring simultaneously in same family members, but to our knowledge, no such cases have been reported in malaria due to P. vivax. We report two cases of P. vivax malaria presented simultaneously in siblings.
| Case Reports|| |
The first case is about a 4-year-old boy who was admitted with the complaints of recurrent fever for 1 month duration. It was a high grade, intermittent and associated with chills and rigors. The fever regularly peaked in the morning and night almost every other day. There was no other localizing symptom. Careful history taking revealed a recent travel to a malaria endemic area 2 weeks before the onset of symptoms. On examination, he was pale, but vital signs were within the normal limits. Systemic examination revealed mild hepatomegaly and moderately firm splenomegaly (6 cm below left costal margin, mid clavicular line). Other systems were within normal limits. Initial blood reports revealed hemoglobin (Hb) - 9.4 gm/dl total leukocyte count (TLC) - 5300 cells/mm 3 , differential counts, neutrophil-37, lymphocyte - 60, eosinophil - 2, monocytes - 1, platelet count was 1,49,000 cells/mm 3 and peripheral smear revealed microcytic hypochromic anemia. Blood smear showed trophozoites, schizonts and gametocytes of P. vivax. Rapid diagnostic test (advantage MAL CARD, J. Mitra and Co. Pvt Ltd, New Delhi, India; ACM080412) for P. vivax was positive. Urine microscopy and culture blood culture and dengue serology were within the normal limits. He was treated with chloroquine followed by curative therapy with primaquine. Fever responded immediately after starting therapy which paralleled regression of spleen size. Repeat blood smear on the day 5 of treatment was negative following which he was discharged home.
Younger brother of case 1 was admitted within 1 day of the former's admission with similar complaints. There was no other localizing symptom. He had accompanied his elder brother during their travel to endemic area. On examination, he was sick looking, pale and had moderate splenomegaly. His blood count showed Hb - 6.9 gm/dl TLC - 9200 cells/mm 3 , differential count neutrophils - 21, lymphocytes - 72, eosinophils - 7. There was reduced platelets count of 67,000cells/mm 3 peripheral smear showed microcytic hypochromic anemia. Blood smear revealed gametocytes of P. vivax. Rapid diagnostic test (advantage MAL CARD, J. Mitra and Co. Pvt Ltd, New Delhi, India; ACM080412) for P. vivax was positive. All other routine investigations were within normal limits.
This child too received chloroquine and primaquine which was followed by immediate clinical improvement. Repeat blood smear on the 5 th day of treatment did was negative for P. vivax and platelet counts returned to normal and he was discharged.
| Discussion|| |
There has been no reports of simultaneous presentation of vivax malaria in siblings. The possible factors that could have facilitated simultaneous transmission are proximity to infective mosquitoes, low socioeconomic class and recent travel to endemic area. Unlike P. vivax, familial cases have been reported with falciparum malaria. An Indian report has documented three cases of falciparum malaria in children of the same family. Two of them developed acute respiratory distress syndrome (ARDS), one developed transient myocarditis, the third child developed hemophagocytosis, all these are unusual complications of falciparum malaria.  The parents did not develop any symptom.
There is another reported series of simultaneous presentation of falciparum malaria in five children belonging to same family following a visit to Nigeria.  Most of these children developed rare life-threatening manifestations such as hyperparasitememia (4.8%) requiring exchange blood transfusion and plasmapheresis, hepatic dysfunction, severe metabolic acidosis, hypoglycemia, hyperbilirubinemia, severe anemia requiring to up blood transfusion and mechanical ventilation. Reports also indicated that all five children had either sickle cell disease (SS) or sickle cell trait (SA). Both the parents travelled along with children but were asymptomatic.
From both these case series, it is apparent that falciparum malaria presenting simultaneously among family members tend to affect children and present with severe, life-threatening manifestations. In contrast to that, none of our cases had any life threatening complications and they were discharged home from hospital within 5 days of therapy. However, both of our patients had self-limiting thrombocytopenia. A descriptive study done on 168 children with vivax malaria identified 7% of cases to have thrombocytopenia.  Complications of P. vivax malaria in children are predominantly hematological and clinical-visceromegaly. The hematological manifestations included anemia, icterus, petechiae and rarely, bleeding manifestations. Other complications include respiratory (ARDS, Pleural effusion), oliguria, shock, myocarditis and cerebral malaria. The complications were more severe in the younger children less than 5 years. 
Children belonging to same family are at risk of developing simultaneous malaria following travel to endemic area. This case series highlights the importance of the need for malaria-prevention measures like appropriate chemoprophylaxis and avoidance of mosquito bites for those travelling to endemic areas.
| References|| |
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