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CORRESPONDENCE
Year : 2012  |  Volume : 57  |  Issue : 3  |  Page : 237-238
Malaria presenting as urticaria


1 Shree Skin Centre, Nerul, Navi Mumbai, India
2 Skin Disease Centre, Nashik, Maharashtra, India

Date of Web Publication16-May-2012

Correspondence Address:
Kiran V Godse
Shree Skin Centre, Nerul, Navi Mumbai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.96213

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How to cite this article:
Godse KV, Zawar V. Malaria presenting as urticaria. Indian J Dermatol 2012;57:237-8

How to cite this URL:
Godse KV, Zawar V. Malaria presenting as urticaria. Indian J Dermatol [serial online] 2012 [cited 2020 Sep 19];57:237-8. Available from: http://www.e-ijd.org/text.asp?2012/57/3/237/96213


Sir,

Malaria is a protozoal infection transmitted to human beings by mosquitoes biting mostly between sunset and sunrise. It is endemic in India, where it has been known to exist for thousands of years. It is present in all parts of the country, except for some mountainous areas and well-drained coastal areas along the Western and Eastern Ghats. [1]

The clinical features vary depending on the species of parasite, the patient's immune state, intensity of infection, and the presence of concomitant conditions. The typical manifestations include fever with chills, splenomegaly and parasitemia. However, atypical presentations of malaria have been reported with Plasmodium falciparum and Plasmodium vivax. Involvement of the central nervous system, cardiovascular system, respiratory system, hemopoietic system and cutaneous manifestations are reported. Hence, malaria is now considered a multisystem organ failure (MSOF) or single-system organ failure. The mortality rate is 6.4% when one organ fails but increases to 48.8% with failure of two or more organs. [2]

This study was done from June 2000 to December 2000 when malaria was epidemic in Navi Mumbai due to migration of workers, extensive construction activity and stagnated water. Smear for malarial parasites were routinely done in all patients to rule out the carrier state.

We report ten patients who presented with urticaria with or without fever as a manifestation of malaria. All of them had malarial trophozoites in the blood and administration of antimalarial treatment cured the urticaria.

Ten patients (six females and four males; mean age, 34 years) presented with a generalized mildly itchy urticarial rash since 3 to 30 days. Fever was present at the time of presentation in three patients. Fever was present for one/two days along with urticaria. Paracetamol was ingested by two patients for fever control. Joint pain was reported by six patients. Generalized malaise, which is never noted in acute urticaria patients, was present in five patients. Antihistamines had provided temporary relief followed by relapse on discontinuation. There was no history of urticaria in the past. Routine investigations for fever and urticaria revealed malarial parasites in complete blood count examination.

All patients had urticarial wheals in size varying from 3 to 10 cm that were erythematous and edematous plaques all over the body, and five had splenomegaly. Angiodedma was not present in these patients. Peripheral blood examination revealed microcytic anemia in six patients. A malarial smear showed ring forms Plasmodium falciparum in six patients and rings and trophozoites of Plasmodium vivax in four patients. The falciparum positive patients were treated with tablet quinine salt 600 mg three times a day for 7 days and the vivax positive patients were treated with chloroquine and primaquine. Chloroquine was given as 600 mg stat (four tablets) and 300 mg (two tablets) after 6 h followed by 300 mg after 24 and 48 h. Later, primaquine was given as 15 mg daily for 14 days to prevent relapse. They were also given cetirizine 10 mg once daily for control of the urticaria. The clinical response to antimalarial treatment was excellent, with rapid recovery from fever and the urticarial rash. The joint pain also resolved. After stopping cetirizine on the completion of antimalarial therapy, there was no relapse of urticaria. There was no relapse of urticaria during follow up for the next 3 months in all patients.

Malarial parasitemia, nonresponsiveness of the urticarial rash to antihistamines and response to antimalarial therapy supports the presumptive diagnosis of malaria being the cause of urticaria in our patients. The incidence of malaria manifesting with urticaria is reported in the range of 1.33% to 25.6%. [3],[4],[5] There are several reports of malaria and urticaria from India. [6],[7] Natarajan postulated that deposition of malarial pigment in the reticuloendothelial system produces IgE and triggers urticaria. [8] This may also occur with a subclinical infection. There is a report of a case of urticarioid manifestation in a patient with imported pernicious cerebral malaria. [9] Talib et al., present 13 cases of malaria for their protean manifestations. Five patients presented for chronic urticaria, with or without polyarticular arthritis, another mimicked acute rheumatic arthritis. A case had reactivation of pulmonary tuberculosis and the other two developed apparent chloroquine resistant malaria who responded to combination of verapamil and chloroquine. [10]

Tumor necrosis factor (TNF) plays important roles in the protection and onset of malaria. Although mast cells are known as a source of TNF, little is known about the relationship between mast cells and pathogenesis of malaria. A study from Japan proposes a novel mechanism that mast cells and mast cell-derived TNF play protective role in malaria. [11] Mast cell activation is the prime pathophysiological event in most forms of urticaria.

In an endemic area, the presentation of fever and urticaria should give physicians a clue of an underlying malarial infection and call for appropriate investigations as early diagnosis and treatment will help to prevent morbidity and mortality due to malaria.

 
   References Top

1.Talib VH. Malaria Indian scenario. Indian J Pathol Microbiol 1996;39:381-90.  Back to cited text no. 1
    
2.Krishnan A, Karnad DR. Severe falciparum Malaria: An important cause of multiple organ failure in Indian intensive care unit patients. Crit Care Med 2003;31:2278-84.  Back to cited text no. 2
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3.Mehta SR, Joshi V, Lazar AI. Unusual acute and chronic complications of malaria. J Assoc Physicians India 1996;44:451-3.  Back to cited text no. 3
    
4.Deb T, Mohanty RK, Ravi K, Bhagat BM. Atypical presentations of falciparum malaria. J Assoc Physicians India 1992;40:381-4.  Back to cited text no. 4
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5.Mishra SK, Satpathy R, Das DB, Nanda NC, Satpathy SK, Mohanty S. A rare presentation of falciparum malaria. J Assoc Physicians India 1995;43:582.  Back to cited text no. 5
    
6.Mitra A. Malaria presenting with urticaria as the initial feature. Indian Pediatr 1989;26:728.  Back to cited text no. 6
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7.Maheshwari N, Maheshwari V, Mobashir M. Plasmodium vivax malaria presenting with urticaria. Postgrad Med J 1989;65:266-7.  Back to cited text no. 7
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8.Natarajan C. Malarial urticaria: A study of 12 cases. In: Jain SK, editor. Delhi: VP Chest Institute. Aspects of allergy and applied immunology XIII-XIV, 1980-1; 1980. p. 86-7.  Back to cited text no. 8
    
9.Loschiavo F, Ventura-Spagnolo T, Di Bella P, Bramanti P. Urticarioid manifestation in course of cerebral imported malaria. Acta Neurol (Napoli) 1993;15:211-4.  Back to cited text no. 9
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10.Talib SH, Gaikwad A, Jirwankar PS. Protean manifestations of malaria (multi-organ dysfunction syndrome). Indian J Pathol Microbiol 1996;39:473-6.  Back to cited text no. 10
    
11.Furuta T, Kikuchi T, Iwakura Y, Watanabe N. Protective roles of mast cells and mast cell-derived TNF in murine malaria. J Immunol 2006;177:3294-302.  Back to cited text no. 11
[PUBMED]  [FULLTEXT]  



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[Pubmed] | [DOI]



 

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