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Description
To make malaria control programme more effective, it is crucial to recognise the Plasmodium vivax (Pv)/Plasmodium falciparum (Pf) confection. A woman in her 50s had a fever and severe throbbing pain in the head for the past 6 days. The symptoms started in the afternoon and the temperature rose to 38.0°C that lasted for an hour. She developed fatigability. She was not diabetic and had no other symptoms. She had not travelled in the previous 6 months; however, sporadic incidences of malaria have been reported in northern part of India where the patient resided. Clinical examination revealed slight pallor and absence of icterus. The liver was palpable just below the costal margin, but the spleen was not palpable. The white cell count was 5.3x10ˆ9/L, with neutrophils 58%, haemoglobin 90 g/L and platelet count 110 000/cmm.
Rapid diagnostic antigen test (histidine rich protein 2 for Pf and lactate dehydrogenase for Pv) was positive for Pv and Pf. A peripheral blood smear (figure 1) collected during the febrile state revealed different phases of Pv including ruptured schizont, and the ring form of Pf.
Peripheral blood smear stained with Leishman under ×200 magnification shows (A) Plasmodium vivax merozoites 14 in no. (arrow) while mature schizont is seen below and right of merozoites; (B) macro-gametocyte (arrow); (C) trophozoite of Plasmodium vivax (arrow above) and intraerythrocytic Plasmodium falciparum ring stage (arrow below); (D) adherence of red blood cells with ring stage of P. falciparum.
It is reported that different malaria parasites coinfecting a host may interact antagonistically to each other or favourably towards one parasite. In one report, Pv was seen to mitigate the severity of Pf and keeps the patient from developing complications since there is some cross immunity between the two species of Plasmodium.1 A meta-analysis of 14 studies found a similar incidence of complications between Pf/Pv coinfection and lone Pf infection.2 The patient was treated to cure both infections using the recommended drug regimen used in the country. These included α/β arteether (150 mg intramuscular daily) for 3 days, with three tablets of sulfadoxin/pyrimethamine (500 mg/25 mg) for Pf and chloroquine 1500 mg was given over 3-day course for Pv. To prevent relapse, primaquine 15 mg was administered daily for 14 days commencing on day 4.
Patient’s perspective
I had severe headache, chills and fever daily in the afternoon for the past 6 days. I got to know I had malaria in two forms. After getting treatment, I am now fine.
Learning points
The clinical presentation and blood indicators of Plasmodium vivax/Plasmodium falciparum coinfection in this patient have been shown to guide management of patients.
Images of peripheral blood smears would contribute to national health laboratory staff’s ability to recognise the parasites towards management and malaria elimination.
Ethics statements
Patient consent for publication
Footnotes
Twitter @manserpur
Contributors RKS is sole author of this image article and he was responsible for drafting of text, sourcing and editing of clinical images and critical revisions for important intellectual content. RKS gave final approval of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.