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Case Report

Congenital Malaria with Atypical Presentation: ASeries of

Three Case Reports
Geeta Gathwala, Poonam Dalal, Mohit Gupta
Department of Pediatrics, Pt. B.D. Sharma, PGIMS, Rohtak, Haryana, India

ABSTRACT
Congenital malaria is among rare presentation of the disease. Neonatal malaria remains extremely rare both in endemic and non endemic areas.
Herein, we report three cases of congenital malaria presenting with prolonged jaundice from a non endemic region of NorthIndia. This may
emphasize the need to consider congenital malaria as a differential diagnosis while evaluating the babies with atypical symptoms like prolonged
conjugated hyperbilirubinemia.

Key words:
Congenital malaria, prolonged, conjugated hyperbilirubinemia

INTRODUCTION (DCT) was negative, and G6PD was normal. Creactive

Malaria in the neonatal period may be acquired by
transfusion of infected blood products to neonate, perinatal
transmission from mother and in endemic areas by mosquito
bite. Congenital malaria is defined as malaria acquired from
the mother prenatally or perinatally.[1,2] The predominant
clinical features are fever, anemia and splenomegaly,
the triad reportedly seen in more than 80% of cases,
presentation as prolonged conjugated hyperbilirubinemia
is far less common.[3] Herein, we report three cases of
congenital malaria presenting atypically.
CASE REPORTS
Case 1
A 17dayold male baby was admitted with yellowish
discoloration of skin and eyes noticed since 8thday of life.
There was no history of fever. The baby was born at term
to a fourth gravida mother with a birth weight of 2.5 kg.
There was a history of fever in the mother at 8thmonth of
gestation, which was high grade and associated with chills
and rigors. Mother was given antimalarials for that and
became asymptomatic. Baby did not receive any blood
products prior to illness. Examination revealed the icterus
up to soles, mild pallor and hepatosplenomegaly with
liver palpable 3cm and soft to firm spleen 3cm below the
costal margin. Laboratory evaluation showed anemia with
hemoglobin (Hb) 11.0 g/dL, total leukocytes 8000/cmm
with 70% polymorphs, 25% lymphocytes, 3% monocytes,
protein(CRP) was positive, blood culture sterile and liver
enzymes(transaminases) were in normal range. Ultrasound
abdomen revealed hepatosplenomegaly. Baby was
diagnosed as a case of congenital malaria and was treated
with chloroquine. Spleen regressed and baby became
anicteric after 1week of treatment.
Case 2
A 21dayold male was admitted with yellowish discoloration
of eyes and skin since day 10 of life and dark yellow urine
and acholic stools since day 20 of life. There was no history
of fever. The baby was born to a primigravida mother at full
term with a birth weight of 3.2kg. Mother was asymptomatic
throughout the pregnancy. The baby did not receive any
blood products in the neonatal period. Examination
revealed pallor, icterus up to the upper abdomen, liver
palpable 3 cm below the costal margin and a soft to firm
spleen palpable 2cm below the costal margin. Aprovisional
diagnosis of prolonged jaundice was made. Investigations
Address for correspondence:
Dr. Poonam Dalal,
Department of Pediatrics, Pt. B.D. Sharma, PGIMS,
Rohtak - 124 001, Haryana, India.
E-mail: drpoonam12@yahoo.com
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2% eosinophils and normal platelet count. Peripheral blood www.jcnonweb.com

film revealed normocytic, normochromic picture and

malarial parasite. Both mothers and babys blood group DOI:
was A +. The total serum bilirubin was 18.8 mg/dL with 10.4103/2249-4847.154128
direct 9.0mg/dL, and indirect 9.8mg/dL. Direct coomb test

206 Journal of Clinical Neonatology | Vol. 4 | Issue 3 | July-September 2015

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Gathwala, et al.: Congenital malaria: A series of three case reports
revealed Hb 7.5 g/dL, total white blood cell 8000/cmm,
polymorphs 25%, lymphocytes 70%, monocytes 1%,
eosinophils 4% and microcytic hypochromic picture on
peripheral blood film. Serum bilirubin was 13.6mg/dL with
direct fraction 6.6mg/dL and indirect 7.0mg/dL. Thyroid
function tests were normal. Mothers blood group was Bve
and the babys was B+ve. However, the DCT was negative
and G6PD was normal. Serum glutamicoxaloacetic
transaminase was 81.0 IU/L, serum glutamic pyruvic
transaminase 29.0 IU/L and the serum alkaline
phosphatase was 509 IU/L. Ultrasound abdomen revealed
no abnormality of the hepatobiliary system. Peripheral
blood film on 2nd day of admission revealed Plasmodium
vivax. A final diagnosis of congenital malaria was made.
The baby was treated with chloroquine. Repeat blood smear
at end of treatment was negative, and the baby responded
with regression of spleen and decreased icterus by 4thday
of treatment.
Case 3
A 38dayold male was admitted with moderate grade
intermittent fever since day 25 of life and yellowish staining
of eyes, skin and urine. The baby was born at term to a first
gravida mother with a birth weight of 3.0kg. Mother had
highgrade fever with chills 1 day prior to delivery and
3 days after delivery. The baby remained asymptomatic
and was not investigated at that time. The mother was
treated with antimalarials and became asymptomatic 2days
after treatment. Examination of the newborn revealed
temperature 101F, marked pallor and hepatosplenomegaly
with liver5cm and spleen 4cm below the costal margin,
and icterus up to the upper abdomen. Investigations
revealed a Hb of 6.0g/dL, total leukocyte count 5000/cmm,
with polymorphs 68%, lymphocytes 28%, monocytes 2%,
eosinophils 2% and a platelet count of 90,000/cmm with
dimorphic anemia on peripheral blood film. The total
serum bilirubin was 12.5mg/dL: Direct reacting 4.5mg/dL,
indirect 8.0mg/dL. DCT and G6PD were negative. Mother
and baby blood groups were O+and B+respectively. Serum
transaminases were normal. The CRP was positive, and
blood culture was sterile. Injectable antibiotics were started
with the provisional diagnosis of late onset sepsis. Thick
and thin blood smears revealed P.vivax on two consecutive
days. Baby was diagnosed as congenital malaria and treated
with chloroquine. Anemia was treated with packed cell
transfusion. Baby became afebrile and peripheral smear
became negative following treatment, spleen regressed by
4thday of treatment and baby became anicteric after 1week.
DISCUSSION
Congenital malaria has been reported as a rare event with
an incidence of 0.3% in malaria immune mothers to 7.4% in
non immune mothers despite 13% incidence of cord blood
Journal of Clinical Neonatology | Vol. 4 | Issue 3 | July-September 2015
parasitemia in endemic countries.[4] Congenital malaria is
mainly caused by P.falciparum in endemic areas, whereas
most cases in European countries are due to P.malariae and
P.vivax.[5]
Clinical onset of disease in a congenitally infected infant
can be delayed for weeks, most of them presenting between
10 and 28days of life.[2,3] All the three index cases became
symptomatic between 8thand 25thday of life. Vottier etal.[5]
reviewed clinical characteristics of all the reported cases
of congenital malaria over last 30years from non endemic
areas. The predominant clinical features reported were
anemia (77%), fever (74%), hepatosplenomegaly (68%),
poor feeding and lethargy (35%). Hemolytic anemia was
reported as most common laboratory finding, although
clinical jaundice was not reported in any of them. In
the index case series, however, all three had conjugated
hyperbilirubinemia, anemia, and splenomegaly, fever was
present in only one of them. Clinical symptoms are rare in
younger infants and absence of febrile episodes has been
described. This has been attributed to transplacentally
acquired antimalarial antibodies, which give transient
protection to young infants.[4]
Del Punta et al.[6] reported a 22 days old neonate
presenting with fever, listlessness, hepatosplenomegaly and
thrombocytopenia, which was incidentally diagnosed with
congenital malaria and responded well to antimalarials.
Similar case was reported by Sankar et al.[7] from a non
endemic area in India. In both the cases, there was a
history of the mother traveling to the endemic area during
pregnancy. In the index case series, one of the three cases
was initially treated as neonatal sepsis and later on was
incidentally diagnosed as congenital malaria. All the three
cases came from a non endemic area (annual parasite
incidence<2) of NorthIndia.
Prolonged conjugated hyperbilirubinemia is mainly
described with neonatal hepatitis and biliary atresia.
Congenital malaria is not mentioned as a cause for
prolonged jaundice in literature except two case reports.[8,9]
Davenport[8] reported a case of transplacentally acquired
malaria with prolonged conjugated hyperbilirubinemia
and liver disease in a 3 weeks old neonate. However,
icterus persisted despite antimalarial therapy in contrary
to index cases where all three became asymptomatic
following antimalarial therapy. Valecha et al.[9] reported
atypical presentation of congenital malaria as jaundice and
hemolytic anemia in a 6weeks old infant and akin to the
three index cases improved with antimalarial therapy.
The incidence of congenital malaria is 0.3% which rises
to 4% following overt attack of malaria in the mother[3]
in endemic areas. In the index case series, maternal fever
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Gathwala, et al.: Congenital malaria: A series of three case reports
was reported in perinatal period in two of the three cases
and was successfully treated with antimalarials. Congenital
malaria has been reported to occur even in the absence of
evidence of active malarial infection in the mother during
pregnancy. Out of 15 cases of malaria in first 4 months,
Dhatt etal.[10] reported positive history of maternal malarial
infection during pregnancy in 50% cases.
Chloroquine given in the dose of 10mg/kg body weight of
the base, followed by 5mg/kg at 6h and 5mg/kg once a
day for next 2days is the accepted treatment regimen. All
the three cases in the index series were successfully treated
with this regimen. Primaquin is not required for treatment
as the exoerythrocytic phase is absent in congenital
malaria.[2,3]
CONCLUSION
The index case series emphasizes the importance of
considering congenital malaria as a differential diagnosis
in neonates even in low transmission area who may
present with atypical symptoms like prolonged conjugated
hyperbilirubinemia rather than the typical triad.
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How to cite this article: Gathwala G, Dalal P, Gupta M. Congenital
malaria with atypical presentation: A series of three case reports. J
Clin Neonatol 2015;4:206-8.
Source of Support: Nil, Conflict of Interest: None declared.
Journal of Clinical Neonatology | Vol. 4 | Issue 3 | July-September 2015