Malaria - A great masquerader
Mr. R, a 32 year old male presented with the complaint of bleeding from his gums after brushing for the past 3 days. He has no comorbidities. His history not significant for fever in the recent past, no history of drug intake, no history suggestive of connective tissue disorders, no history of a similar bleed in the past, no family history of any bleeding disorder. No history of surgeries or blood transfusions. Except for the mucosal bleed and a few purpuric spots his physical examination was unremarkable. Vitals signs normal. No fever. His investigations showed a hemoglobin of 11.2 g/dl, a normal white cell count and normal PT and APTT. However is bleeding time was prolonged and his platelet count was 130!!! (normal - 1.5 to 4 lakhs/cu.mm. ). His usg abdomen was normal. Viral markers were negative including HIV and hepatitis viruses. ANA is negative.Thick and thin smears for malaria was negative. Other investigations to identify the cause of thrombocytopenia turned out to be normal. He was in the meantime he was started on the platelet transfusions but the rise in the count was poor. He was started on methylprednisolone presumptively but there was no response. In view of his persistent low platelet count(around 100) he was posted for a bone marrow aspiration and biopsy, inspite of the bleeding risk. Bone marrow biopsy was uneventful. It was a pleasant surprise for us when we got a call from the pathology lab the same evening saying that the smears of the aspirate were showing gametocytes of P.falciparum. We started him on artesunate on the same day. The count rose to 5000 the very next day. Then it rose to 15000 the next day and in 2 days hence it was 100,000. We were happy and so was the patient. So please don't ignore malaria as a cause of thrombocytopenia especially in the endemic areas and even if there is a negative thick and thin smear for malaria!!!