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May 1984, Volume 34, Issue 5

Case Reports

Combination of Malaria and Visceral Leishmaniasis in a Child of Two Years.

Hassan Abu Muzaffar Farooqui  ( Department of Hematology and Haemorrhagic Disorders Jeddah, Regional Laboratory Jeddah, Saudi Arabia. )
Mohammad Abdul Aziz  ( Department of Hematology and Haemorrhagic Disorders Jeddah, Regional Laboratory Jeddah, Saudi Arabia. )

Abstract

A case of combined infection of Plasmodium falciparum and leishmania donovani in a child of two years is presented. It occured in a small vifiage Bani-Masawa (Yemen) near Saudi Arabian border from Jizan side, indicating absence of cross immunity or interference between the two parasites. It also reveals that visceral leishmaniasis is present in that area and should be considered in the differential diagnosis of Pyrexia in the patients from the adjacent southern region (JPMA 34: 138, 1984).

Case Report

A two year old girl from a small village Bani-Masawa (Yemen) near Saudi Arabian border from Jizan side, was admitted in the Jeddah Maternity and Children Hospital with a 6 days history of fever with rigors. Blood taken on the day of admission, revealed plenty of ring forms of Plasmodium falciparum. Other hematological findings were of severe anemia and moderate leukocytosis with lymphocytic preponderance.
She was transferred to Al Mahjar Hospital, where peripheral blood film was examined and the diagnosis of Plasmodium falciparum was re-established. The patient was put on anti-malarial therapy (canioquin) to which she responded satisfactorily, but fever started rising again from the third day after therapy, to assume a cyclic pattern. This paradoxical response was considered to be either due to a falciparum strain resistant to drug used or some other etiology for Pyrexia.
The clinical and laboratory data was rescrutinised and further investigations were carried out to arrive at a conclusion to that effect.
Clinically the patient was severly anemic for which she was transfused again . Lymph nodes were enlarged , spleen was palpable three fingers and liver two fingers. There were no complaints pertaining to other systems and no fIndings in abdomen and chest, XRay chest was also clear. There were no urinary complaints and routine examination of urine gave no evidence of urinary tract infection. Widal test was negative serum bilirubin was within normal range.
Repeated blood films for malarial parasites proved to be negative except on one occasion whence upon adrenaline provocation, deformed ring forms were found in very small numbers in a thick film from centrifuged RBC concentrate (plasma thrown out). Concomittant hemato. logical fmdings revealed improvement of hemoglobin level following blood transfusion, leukocytosis was variable with preponderance of lymphocytes.
Bone marrow examination of the patient (Chaterjee, 1976; Mansor Behr and Wilcox,1968) helped to clinch the diagnosis. The marrow was normocellular but full of leishmania donovani bodies, both intracellularly in the large mononuclears and extracellularly. Furthermore, aldehyde test (Chaterjee ,1976) on the serum was positive. .The patient improved in a weeks time after pentostam therapy, but the parents took her home against medical advice.
The relevant laboratory data before and after anti-malarial therapy is presented in table I & II respectively.


Discussion

Plasmodium falciparum infection had commonly been seen by us in patients from southern region, as well as cases of cutaneous Leishnianiasis by leishmania tropica. The area is known to be endemic for both.
Visceral leishmaniasis is known to be endemic in Bangladesh, Assam province of India and Burma (Cecil, 1975) the nomenclature of the disease Kala-azar is of local origin there (Cruickshank et al., 1973).
The combination of visceral leishmaniasis and malaria has been reported in China (Manson Bahr and Wilcox, 1968) that indicates that both parasites can co-exist and that there is no cross immunity as such. We have for the first time come across a patient with coincident combination of visceral leishrnaniasis and Plasmodium falciparum infection. This was also first case cf visceral leishmaniasis from an area known to be endemic cnly for cutaneous leishmaniasis. Our finding confirms the possibility of coexistence of malaria and visceral leishmaniasis and also point towards taking into consideration the possibility of existence of visceral leishmaniasis in areas known to be endemic only for cutaneous leishmaniasis.
The condition having not been met with frequently from such areas could be due to the lesser incidence of the infection or non application of the proper diagnostic approach. It is therefore suggested that in cases of pyrexia from areas known to be endemic for cutaneous leishmaniasis and malaria, the possibility of visceral leishmaniasis should be considered in’ the differential diagnosis and proper diagnostic proce­dures adopted to confirm the diagnosis.

Acknowledgements

We like to thank Dr. Siham Mustafa of Al Mahjar Hospital for referring the case and all around cooperation in accomplishing the case report.
Thanks are also due to Dr. Faisal Jameel Rowaihy, Director Jeddah Regional Laboratory for encouragement and to Mr. Rizal Rodeo for typing arid proof reading.

References

1. Cecil, R.L.F. Textbook of medicine 14th ed by Faul B. Beason and Walsh McDermott. Philadelphia, Saunders, 1975, p.490.
2. Chaterjee, K.D. Parasitology (protozoology and helminthology) in relation to clinical medicine 11th ed. Calcutta, Author, 1976, p. 54.
3. Cruickshank, R., Duguid, J.P., Marmion, BP. and Swain, R.H.A. Medical microbiology. 12th ed. Edinburgh, Churchill Livingstone, 1973, 569.
4. Manson, P. and Wilcocks, C. Tropical disease 16th ed. London, Bailliere Tindall, 1968, p.107.

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