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 Introduction:
Malaria is an endemic disease in the
North of Iraq, it is caused by plasmodium
vivax. Malaria is still an overwhelming
problem in tropical developing countries
with an incidence of more than 100 Million
cases and 1-2 million deaths per year
(1). Occasionally, malaria may present
with unusual signs and symptoms, resulting
in a delay in diagnosis. We report a case
of malaria, which presented with an itchy
pruritic rash, fever and splenomegaly.
Case Report:
A 38 year old woman presented with a
3 days history of continuous low-grade
fever, general ill-health and 2 days history
of an itchy urticarioid rash involving
all of her limbs and trunk (figure 1).
Her local general practitioner had prescribed
an Antihistamine, Paracetamol and Hydrocortisone
cream. Two days later she was admitted
to the hospital since she failed to improve.
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Fig. 1 Urticarioid
Rash
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Her previous medical history was uneventful,
there was no history of any allergic conditions
and she had not been on any medications
prior to her presentation.
On examination she was unwell, febrile
with a temperature of 38.1 °C and there
was generalized urticarioid rash allover
her body but sparing the face. There was
no evidence of sore throat and spleen
was barely palpable. The rest of the examination
was unremarkable. Full blood count, urea
and electrolytes, liver function tests,
bone profile and chest x-ray were all
normal. Urine dipstix showed I + white
cell but urine and stool culture showed
no evidence of infection. Monospot test,
Widal test, Brucellosis serology, Viral hepatitis serology, Syphilis serology,
repeated blood cultures, Antinuclear antibody
and rheumatoid factor were negative. Erythrocyte
sedimentation rate was 35 millimeter/hour
and C-reactive protein was 60 nanograrn/
litre.
Over the following 4 days she continued
to run low-grade pyrexia and her rash
almost unchanged. She was treated with
Paracetamol and Antihistamines. In hospital
on day four, a blood film was positive
for plasmodium vivax. She was commenced
on Chloroquine followed by Primaquine.
Her temperature settled 24-hours later
and within 48 hours her rash disappeared
completely with no further pruritis. She
was discharged on day six on a two-week
course of primquine. The rash did not
recur over a 6 month period of follow
up.
Discussion:
It is important to be aware that malaria
may present with unusual presentations.
Many presentations and complications have
been described, i.e. acute abdomen, unexplained
tachypnoea, nausea, vomiting, pulmonary
oedema, multiple organ dysfunction, malaena,
hepatitis-like illness, gastrointestinal
haemorrhage, cerebellar ataxia, tremors
and haemoptysis (2, 3). A pruritic rash
has also been mentioned in association
with nausea, vomiting, diarrhoea and cerebral
malaria (4,5).
Dermatological manifestations of malaria
in most of the case reports have been
linked to Falciparum Malaria. We believe
this is one of the few case reports linking
Plasmodium Vivax with an urticarioid rash
(6,7). The exact mechanism of skin manifestation
in Malaria is not clear. But it could
be a part of the generalized allergic
reaction to the Malarial parasite or to
the high level of Cytokines, especially tumor
necrosis factor (5). As a consequence
of this case two more patients with identical
presentation were diagnosed in the same
hospital without delay.
Conclusion:
Physicians, GPs and Dermatologists, especially in endemic areas, should be aware that Malaria might
first present with skin lesions. In many countries Malaria is still the commonest cause for fever in patients requiring
hospitalization after returning from tropical areas (8). Early detection and treatment may prevent secondary complications and improve ultimate prognosis.
References:
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