Congenital Malaria with Atypical Presentation in a Preterm Neonate
A 16-day-old male child was admitted with complains of refusal to feed and poor activity. The baby was delivered at the gestational age of 32-34 weeks, in the same hospital by cesarean section. Activity, Pulse, Grimace, Appearance, respiration score at 1 min and 5 min was 7/10. The mother was primigravida. He had been admitted on 1st day of life for low birth weight (1,500 g) and poor activity. Rooting and Sucking reflex was poor. There was no organomegaly. The baby was not taking mother′s breast milk but was tolerating spoon feeding. Sepsis screen was negative and Hb% was 14 g%. The baby was treated with intravenous antibiotics and fluids for probable sepsis and was discharged after 4 days of admission on repeated requests of parents. The baby came in the out-patient department on 10th day of life for follow-up. The baby was still on spoon feeding and there was no weight gain (weight = 1,480 g). In order to find the cause of failure to gain weight in the baby, admission of the baby was advised, but parents refused. Hence, sepsis screen was performed on the out-patient basis and it came out to be negative. On present admission, the child was lethargic and was not tolerating even spoon feeding. Cry was very weak. Weight was 1,420 g. Pallor was marked. Except for mild tachycardia, vital signs were stable. On abdominal examination, hepatosplenomegaly was present. On 2nd day of admission, the baby developed icterus. The direct fraction of serum bilirubin (T = 9.6 mg/dl, D = 4.6 mg/dl, ID = 5.0 mg/dl) was elevated. The jaundice was pathological. Sepsis screen (total leukocyte count = 8500/mm3, platelet count = 96300/mm3, C-reactive protein = negative, band cells = 5%) was again negative. Hb% had decreased to 11 g%. The peripheral blood smear examination showed the presence of plasmodium vivax. A provisional diagnosis of CM was made. This prompted us to take the gestational history once again. The mother then gave a history of fever with chills at third trimester of pregnancy, for which she was treated with some drugs. The documented evidence of the laboratory reports and drugs were not available. Furthermore, the family was a resident of a malaria endemic area. The baby was treated with oral chloroquine at the standard cumulative dose of 10 mg/kg given in divided doses over 3 days. Blood transfusion with packed cell was also carried out. After completion of the course of chloroquine, the baby showed marked improvement in activity. The icterus disappeared. He started to take mothers breast milk normally. There was a decrease in spleen size. The baby was discharged on nutritional supplements and was on regular follow-up. After 1 month of discharge, the baby had significant weight gain (weight = 2,700 g), pallor subsided (hemoglobin% (Hb%) =17.6 g/dl), spleen was not palpable and the baby was active and playful and was on a full breast feeds.