Atypical presentation of malaria in Sri Lanka associated with chloroquine resistance

Abstract

Abstract : The classical clinical picture of malaria is one of paroxysmal fever with chills arid rigors. However in the recent past we have encountered an increasing number of Plasmodium falciparum patients with a widely different range of atypical presentaions as reported here. Four such patients described here include a 45 year old male with severe anaemia of 7 months duration who received numerous blood transfusions, a 47 year old male with an intermittent low grade fever of 2 years duration, a 4 year old girl with generalised oedema and a 50 year old male with loss of weight and low grade fever of 3 months duration. Before presenting to us, all these patients had been extensively investigated, yet undiagnosed and received treatment with a full standard course of chloroquine and primaquine. All patients incurred significant morbidity either because of the severity of the disease or long standing nature of the illness due to undiagnosed chloroquine resistant malaria but fully recovered after treatment with sulphadoxinel pyrimethamine. The diagnosis of resistant malaria was made on detection of ring stages of P. falciparum in their blood films and ruling out the possibility of reinfection. These cases are typical of the presentation of malaria infections which are partially resistant to chloroquine (RI and RII), showing that the treatment of such infections with chloroquine leads to the development of clinical immunity, a state in which the patient continues to maintain a low grade blood parasitaemia either in the absence of symptoms or the presence of persistently chronic or atypical symptoms and continuing pathology. In view of the findings reported here and the fact that the incidence of chloroquine resistant malaria in Sri Lanka is increasing, atypical clinical disease should alert physicians to malaria.