Clinical manifestations
The two adult patients aged 35 and 36 years, respectively presented almost similar clinical manifestations having high-graded fever of 390C and 38.50C, respectively. On admission both the patients had higher heart rates and abnormal breathing issues. Clinical assessment revealed no neurological and lymphatic abnormalities, but had palpable splenomegaly on admission. Detailed information on physical and clinical manifestations is presented in Table 1.
Table 1
Physical and clinical characteristics of two adult patients
Parameter
|
Patient 1
|
Patient 2
|
|
Day 0
|
Day 1
|
Day 7
|
Day 0
|
Day 1
|
Day 7
|
Weight (kg)
|
66
|
65
|
64.5
|
60
|
60.8
|
59
|
Height (cm)
|
165
|
165
|
165
|
162
|
162
|
162
|
Blood Pressure (mmHg)
|
130/70
|
150/100
|
124/84
|
140/90
|
130/88
|
126/82
|
Axillary temperature
|
39 °C
|
37.5 °C
|
36.8 °C
|
38.5 °C
|
37.2 °C
|
36.4 °C
|
Heart rate (bpm)
|
100
|
84
|
72
|
88
|
84
|
76
|
Eyes
|
Burning sensation
|
Normal
|
Normal
|
Burning sensation
|
Normal
|
Normal
|
Throat
|
Sore
|
Normal
|
Normal
|
Sore
|
Normal
|
Normal
|
Chest
|
Burning sensation
|
Normal
|
Normal
|
Burning sensation
|
Normal
|
Normal
|
Neurological system
|
Normal
|
Normal
|
Normal
|
Normal
|
Normal
|
Normal
|
Lymphatic system
|
Normal
|
Normal
|
Normal
|
Normal
|
Normal
|
Normal
|
Chills
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
No
|
Headache
|
Yes
|
Yes
|
No
|
Yes
|
Yes
|
No
|
Nausea
|
Yes
|
No
|
No
|
Yes
|
No
|
No
|
Vomiting
|
Yes (3 times)
|
No
|
No
|
Yes (> 3 times)
|
Yes
|
No
|
Cough
|
Yes
|
Yes
|
No
|
Yes
|
No
|
No
|
Shivering
|
Yes
|
No
|
No
|
Yes
|
No
|
No
|
Loss of Appetite/ Anorexia
|
Yes
|
Yes
|
No
|
Yes
|
No
|
No
|
Fatigue
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
No
|
Myalgia (back and limbs)
|
No
|
No
|
No
|
No
|
No
|
No
|
Jaundice
|
Yes
|
Yes
|
No
|
Yes
|
No
|
No
|
Hepatomegaly
|
No
|
No
|
No
|
No
|
No
|
No
|
Splenomegaly
|
Palpable
|
Palpable
|
No
|
Palpable
|
Palpable
|
No
|
Haematological and biochemical analyses
On the day of admission i.e. day 0 both the patients presented abnormal haematological and biochemical parameters compared to the reference range (Table 2). However, total leukocyte count, total protein, albumin and globulin and their ratios were within the reference ranges. Patient 2 had severe anemia and acute kidney injury. Both patients presented hypoglycemia and clinical jaundice. Further details on haematological and biochemical test results are shown in Table 2.
Table 2
Serological, haematological, and biochemical test results of two adult patients.
Parameter
|
Patient 1
|
Patient 2
|
HIV
|
Negative
|
Negative
|
HBsAg
|
Negative
|
Negative
|
Hb (g/dl)
|
11.1
|
6
|
TLC (per mm3)
|
6900
|
6000
|
PCV %
|
34.9
|
30
|
Total RBC (million/mm3)
|
3.87
|
3.69
|
Platelet counts (per mm3)
|
24000
|
50000
|
Blood sugar (mg/dl)
|
45
|
49
|
Serum urea (mg/dl)
|
58.4
|
49
|
Serum creatinine (mg/dl)
|
0.66
|
11
|
Total bilirubin (mg/dl)
|
8.37
|
3.89
|
Direct bilirubin (mg/dl)
|
3.5
|
2
|
Indirect Bilirubin (mg/dl)
|
4.87
|
1.95
|
AST levels (IU/L)
|
96.5
|
96
|
ALT levels (IU/L)
|
70
|
56.7
|
Alkaline Phosphate (IU/L)
|
563.3
|
389.9
|
Total Protein (g/dl)
|
6.54
|
7.91
|
Albumin (g/dl)
|
3.85
|
3.98
|
Globulin (g/dl)
|
2.69
|
2.5
|
A:G Ratio
|
1.43
|
2
|
Parasitaemia/µl
|
16,68,824
|
3,04,000
|
Asexual %
|
100%
|
13,6,800 (46%)
|
Sexual %
|
0
|
16,7,200 (54%)
|
Male gametocyte %
|
0
|
51%
|
Female gametocyte %
|
0
|
49%
|
Patient 1
The microscopic examination of peripheral blood smears confirmed only asexual stages of P. falciparum parasites based on typical morphological characteristics. Parasitaemia was 1668824/ml of blood based on thick smear examination and 42% on thin smear. Fig. 1 A and B show thick smear images, and Fig. 1 C and D are thin smear images. A large number of typical chromatin dots of ring form are seen on thick smears (Fig. 1 A and B). The parasitological assessment of thin smear for species identification was the cytoplasm, which makes the complete ring formation in young trophozoites followed by; thickening and invariably contains several vacuoles to develop the trophozoites. The chromatin (parasite nucleus) was characteristically contained as a single bead, double bead forms on thin smear examination (Fig. 1 C). The most important feature of the rings was found on the margin or edge of the red blood cells, called ‛accolé/appliqué’ forms (Fig 1. C and D). Accolé forms were seen in early stage of P. falciparum parasites and these are three distinct types – common form, rim form and displaced form (16%). The large mass of golden brown pigment (haemozoin) was seen in the pre-schizont and schizont stage (20%). A low number of pigmented monocytes (0.19%), neutrophils (0.29%), and eosinophils (0.09%) was detected (Fig. 1 A). The unusual of marked multi parasitism (74.02%, 1 parasite/RBC; 14.95%, 2 parasites/RBC; 7.7%, 3 parasites/RBC; 3.14%, 4 or more parasites/RBC; 0.19%) was observed (Fig. 1 C and D). No sexual forms i.e. gametocytes were detected in this patient.
Patient 2
Patient 2 had mixed stages of parasites. Total parasitaemia on thick smear was 304000/ml of blood, and 9.5% on thin smears (Fig. 2 A to D). Infected RBCs in thin smear were normal in size and contained young rings, and in some mature stages, showing occasionally thin accolé/appliqué forms (Fig. 2 C). Asexual stages constituted about 46% of 9.5% parasitaemia. Occasional pigments were evident in mature trophozoites and schizonts. Phagocytosed monocytes, macrophages and polymorphonuclear neutrophils were also detected. Different developmental stages of gametocytes ‒ the sexual stage of the parasite, were seen in both thick and thin peripheral blood smears (Fig. 2 A to D) constituted about 54% of 9.5% parasitaemia. The female gametocyte or macrogametocyte is more slender and longer than the male, cytoplasm is deep blue in colour and nucleus is small, compact, staining dark red in colour, but the male gametocyte or microgametocyte is border than female, sausage shaped, cytoplasm is either pale blue or tinted pink, nucleus is staining dark pink in colour was seen in peripheral thin blood smear. Pigments and nucleus were dispersed (Fig. 2 A to D). Some fragmented gametocytes were also detected (Fig. 2 C). In this patient, 54% of 9.5% parasitaemia were gametocytes comprising 51% males and 49% females (1:1). Pigmented neutrophils (1.2) and monocytes (0.4%) were present (Fig. 2 A and B). The unusual of marked multi parasitism asexual (14.5%), sexual (4.5%) comprising male gametocyte (2.3%) and female gametocyte (2.2%), 1 parasite/RBC (4.6%), 2 parasites/RBC (0.4%), 3 or more parasites/RBC (0.2%), schizonts (0.25%) and accolé/appliqué forms 1.5% were found.