Syed Ahmed Zaki & Preeti Shanbag

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J Vector Borne Dis 48, December 2011, pp. 245–246Case ReportsPlasmodium vivax malaria presenting with skin rash - a case reportSyed Ahmed Zaki & Preeti ShanbagDepartment of Pediatrics, Lokmanya Tilak Municipal General Hospital and Medical College, Sion, MumbaiKey words   Angioedema; antihistaminics; atypical; malaria; rash; skin urticariaMalaria is a major disease of public health impor-tance with a high morbidity and mortality. In endemicregions, malaria can present with unusual features due todevelopment of immunity, increasing resistance to anti-malarial drugs, and the indiscriminate use of antimalarialdrugs1. Such unusual presentations of malaria can lead todelayed diagnosis and complications. We herein report agirl with vivax malaria presenting with skin rash.Case report: A 9-yr old Indian girl presented with skinrash and fever for 2 days. Fever was high grade, continu-ous and was associated with chills and rigors. There wasno history of any cough, cold, drug intake, abdominal pain,vomiting, bleeding manifestations, diarrhoea or urinarycomplaints. On admission she had a heart rate of 104/minrespiratory rate of 24/min and blood pressure of 104/70mmHg. Throat examination was normal. Pallor waspresent. Skin examination revealed multiple erythematousand papular skin lesions involving bilateral upper and lowerlimb (Fig. 1). Lesions were mildly itchy. Oral mucosa wasnormal. Liver was palpable 2 cm below the right costalmargin with a span of 6 cm. Spleen was palpable 1 cmbelow the left costal margin. Other systemic examinationwas normal.  Investigations done on the day of admissionrevealed: hemoglobin 8.2 g/dL, total leukocyte count11,200/mm3, and platelet count 1.7 lac/mm3. Peripheralblood smear showed trophozoites of P. vivax.  OptiMaltest was positive for vivax malaria. Dengue NS1 antigentest and dark ground microscopy for leptospira were nega-tive. Her liver function tests, renal function tests, serumelectrolytes and urine microscopy were normal. She wastreated with chloroquine along with antihistamine. Rashdisappeared completely on the third day of admission. Thepatient was given primaquine for 14 days for radical cure.She is well on follow up after six months.Cutaneous lesions in malaria are rarely reported andinclude urticaria, erythema, angioedema, petechiae, pur-pura, and disseminated intravascular coagulation2. Cuta-neous lesions have been described with both falciparumand vivax malaria2. Although the exact pathogenesis ofskin lesions in malaria is not known, these may reflectpart of different immunological consequences during ma-larial infection.  Mast cell activation plays a central rolein the pathophysiology of malaria3. Degranulation of mastcells during various stages of malarial infection releases aconstellation of mediators like histamine, serotonin, hep-arin, proteoglycans, prostaglandins, leukotrienes, plateletactivating factor (PAF), cytokines and tumor necrosis fac-tor2. These mediators cause increased vascular permeabilityand vasodilatation. PAF causes aggregation of humanplatelets, wheal and flare response with late phaseerythema. Leukotriene-induced wheal-flare response islong lasting and associated with endothelial activation andup-regulation of adhesion molecules4,5. Both IgG and IgEcontaining immune complexes are elevated in malaria andprobably play a role in pathogenesis6. IgE containing im-mune complexes are associated with complicated malarialinfection. Deposition of such immune complexes in cuta-Fig. 1: Clinical photograph showing multiple discrete erythematousand papular skin lesions involving both the lower limb J Vector Borne Dis 48, December 2011 246neous vessels may result in local vasculitic damage andskin lesions. Thus, urticaria and erythema are usually dueto histamine and/or other mediators like platelet activat-ing factor (PAF) and leukotrienes. Purpura and petechiaemay be a result of thrombocytopenia, cytoadherance, lo-cal vasculitis and vessel damage from immune complexinjury2. Maheshwari and Gupta have reported nine casesof malaria presenting with urticaria as the initial feature7.The urticaria subsided in all these patients within 12–48 hof starting antimalarial treatment. Urticaria was attrib-uted to direct effect of parasite on mast cells releasinghistamine, involvement of complement system, and intenseelevation of IgG antibodies.Although the cutaneous lesions in malaria are not spe-cific, but when associated with systemic features includ-ing peripheral smear can help in the diagnosis of malaria.In conclusion, physicians, especially those in endemic ar-eas, should be aware of the varied manifestations so thatthe diagnosis and treatment are timely and morbidity andmortality minimized.REFERENCES1. Singh UK, Kumar R, Sharma VK. Increased urinary frequencyas a presentation of Plasmodium falciparum malaria. PediatrInfect Dis J 1994; 13: 1024.2. Vaishnani JB. Cutaneous findings in five cases of malaria. In-dian J Dermatol Venereol Leprol 2011; 77: 110.3. Upreti V, Gera V, Chamania LC, Shetty RA, Chopra M. Ma-laria: the master masquerader. Medical J Armed Forces India2006; 62: 390–1.4. Steinhoff M, Griffiths CE, Church MK, Luyer TA. Inflamma-tion- mediators of inflammation. In: Burn T, Breathnach S, CoxN, Griffith C, editors. Rook’s TB of dermatology, VII edn. Mas-sachusetts, USA: Blackwell Science 2004; p. 1–67. 5. Wasserman SI. Biological mediators of allergic reaction. In:Grammar LC, Greenberger PA, editors. Pattorsons allergic dis-ease, VI edn. Philadelphia, USA: Lippincort William andWilkins 2002; p. 55–63. 6. Mibei EK, Otieno WO, Orago AS, Stoute JA. Distinct patternof class and subclass antibodies in immune complexes of chil-dren with cerebral malaria and severe malarial anaemia. Para-site Immunol 2008; 30: 334–41.7. Maheshwari RK, Gupta BD. Urticaria in malaria. Indian Pediatr1984; 21: 663.Correspondence to: Dr Syed Ahmed Zaki, Assistant Professor, Department of Pediatrics, Lokmanya Tilak Municipal General Hospital andMedical College, Sion, Mumbai–400 022, India.E-mail: drzakisyed@gmail.comReceived:16 September 2011 Accepted in revised form: 24 October 2011

Plasmodium vivax malaria presenting with skin rash - a case report

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