Congenital Plasmodium Vivax Malaria and Intracranial Hemorrhage

Abstract

To the Editor : Congenital malaria is extremely rare, both in endemic and non-endemic countries. A case of congenital malaria due to Plasmodium vivax , who presented with uncommon features of recurrent seizures and intracranial hemorrhage is described. A 12-d-old boy was admitted with fever of 7 d, poor feeding and occasional vomiting. The baby developed recurrent seizures and pallor one day prior to referral. On admission, he had a body temperature of 38.7 °C, pallor, mild icterus and hepatosplenomegaly. Blood sugar and serum electrolytes were normal. Hb% 6.7 g/dL, Hct – 20.3 %, reticulocyte count – 3 %, TLC – 4,800/cmm, N – 34 %, L – 62 %, M – 2 %, E – 2 % and platelets – 120,000/cmm, ESR – 35 mm/h. Total serum bilirubin – 6.5 mg/dL, CRP – 1.6 mg/dL. PT and aPTT were normal. Blood and urine cultures as well as CSF study and chest radiograph were normal. One unit of packed RBC was transfused on the day of admission. Seizures recurred, for which midazolam infusion was started along with maintenance doses of inj. phenobarbitone and phenytoin. CT scan of brain was done which showed intracranial hemorrhage in left parietal region. For persistence of fever and pallor, complete blood count was repeated along with peripheral blood smear which revealed Plasmodium vivax . His mother was positive for P. vivax as well. The baby was treated with injection quinine and the mother was treated with oral chloroquinine and primaquine. Both the baby and the mother had negative blood smears after 3 d of antimalarials. Before discharge, one more transfusion with packed RBC was required and all anticonvulsants were stopped. Repeat CT scan of brain was done 3 mo after the discharge and it was normal. At one year follow-up, there was no recrudescence of fever or recurrence of seizure. Growth and neurodevelopment of the infant is normal. Malaria contributes significantly to perinatal disease burden and information on congenital malaria, in terms of prevalence and outcome is not well described in literature [1]. Clinical features of congenital malaria include fever, anemia, hepatosplenomegaly, poor feeding, lethargy, irritability and jaundice. This case showed additional features like recurrent seizures and intracranial hemorrhage [2, 3]. Postulated mechanisms for congenital transmission of malaria include maternal transfusion into fetal circulation either during pregnancy or at delivery, direct penetration through chorionic villi or penetration through premature separation of placenta [4]. Exact mechanism of intracranial hemorrhage in congenital malaria is not known but literature supports the view that malariaassociated cerebral vasculitis can cause small, punctate brain hemorrhages [5]. We conclude that congenital malaria can present with atypical features like seizures and intracranial hemorrhage. More studies are needed to know the mechanism of pathogenesis of these atypical features of congenital malaria. S. Sahoo Department of Pediatric Medicine, Dr B. C. Roy Postgraduate Institute of Pediatric Sciences, 111, Narkeldanga Main Road, Kolkata, India