Investigation & Treatment:
A provisional diagnosis of malaria was made. A rapid malaria antigen
test revealed positive for Plasmodium vivax , and serological
tests for typhoid, dengue, scrub typhus, brucella, Leptospira,
hepatitis, and HIV were negative. A blood sample was sent for G6PD
analysis to a nearby laboratory. Laboratory investigations on the day of
admission (day 0) revealed normal hemoglobin levels (12.8mg/dl),
leukopenia (3370/mm3), thrombocytopenia (45,000/mm3), and a USG of the
abdomen and pelvis revealed a few calculi in the lumen of the
gallbladder, with one measuring 7 mm. He was admitted to the hospital
and given IV paracetamol 1 gm, IV pantoprazole. He was also started on
Tab. Chloroquine 10 mg per kg (600 mg for 2 days and 300 mg on the third
day) and Tab. Primaquine 0.25 mg per kg (15 mg for 14 days) as per the
National Malaria Treatment Protocol 2019(10).
On day 1, the definitive diagnosis of Plasmodium vivax malaria
was confirmed from a peripheral blood smear. Spectrophotometry showed a
total G6PD activity of 8.4 U/g Hb, which is well within the normal
range. Hemoglobin had dropped to 11.7 g/dl, but within the normal range
for the treatment of malaria. Investigations revealed hyperbilirubinemia
(4.2 mg/dl). The cytology report revealed normocytic normochromic anemia
with thrombocytopenia. There were no signs of icterus. Primaquine
continued. On day 2, the lab results showed decrease in hemoglobin (9.8
g/dl), and hyperbilirubinemia (4.2 mg/dl). The drop in hemoglobin was
still within the normal limit and since there were no clinical symptoms,
PQ was continued. On day 3, hemoglobin dropped further to 9.5 g/dl. PQ
was withheld and the patient was kept under close observation of his
vital signs and further laboratory workup. The laboratory parameters
improved from day 4.