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.