Falciparum malaria cases baffle city doctors

MUMBAI: Twelve-year-old Sameer and his 10-year-old brother Rajul recently were hospitalised after a weeklong bout of intermittent fever and severe headaches.
Their family physician suspected malaria, but bloodsmear tests came up negative each of the five times the brothers took it.
The boys, who come from an affluent family that lives in Chowpatty, were admitted to a leading private hospital.
Doctors there suspected typhoid.
But again, tests came up negative. On their second day in hospital, both broke into a high fever. The younger boy suffered convulsions on the third morning and went into a stupor that lasted 48 hours.
Baffled, the doctors ordered an antigen test, which detects malarial parasites in blood. Again, the results were negative. Nonetheless, the doctors decided to trust their clinical judgement and started treatment for typhoid and falciparum malaria.
The children soon responded. Stories like this one— which was reported by Dr Rajan Unadkat, a consultant paediatrician at Bhatia Hospital —are being repeated all across the city, from Panvel to Colaba. But in addition to the spike in the incidents of falciparum malaria, doctors say that they''re worried by the parasite''s unorthodox behaviour.
For Sameer and Rajul (not their real names), the parasite finally was traced through the little-used Elizabased IGM malaria antibody test. Doctors said that the parasite''s tendency not to show up on standard tests is making diagnosis and treatment difficult.
Though Mumbai''s health authorities refuse to admit an increase in falciparum malaria, pointing to comparative data from public hospitals over the last couple of years, there''s plenty of anecdotal evidence to show that incidents of the disease have soared.
Experts note that the municipal corporation does not receive malaria data from doctors in private practice, who initially treat the majority of patients, both rich and poor.
For instance, Dr M. Lad, a physician at Arunoday Clinic in New Panvel, said that 70 per cent of his admissions are falciparum cases. He blames this on uncontrolled construction activity, a breakdown in sanitation, and the influx of migrant labourers.
The problem starts when a patient goes to a general practitioner complaining of intermittent fever and severe headaches, and sometimes with the symptoms of jaundice.
"Many doctors fail to suspect malaria or catch the infection early enough. This leads to complications," says Abha Nagral, infectious disease specialist at Bhatia and Kasturba Hospitals.
Nandkumar Padhye, a professor of medicine at the state-run GT Hospital who has treated more than 150 patients with falciparum malaria over the past five years, said that his patients have presented a variety of symptoms that don''t follow the text-book norms. He now associates organ failure, acute psychosis, itching, fever and rigours with falciparum malaria.
He added that when blood platelet counts drop and patients fail to respond to chloroquin treatment, doctors should suspect falciparum malaria, dengue or leptospirosis.
In such crisis situations, the IGM antibody test could help decide whether the patient should be hospitalised for anti-falciparum treatment despite the smear-negative results.
According to Dr James D''-Costa, whose pathology lab finally diagnosed that Samir and Rajul had falciparum malaria, about 50 per cent of the smear-negative malaria cases he''s seen in the last eight years have tested positive with the IGM test. Many of these cases presented unusual symptoms not normally associated with falciparum: neuro-psychiatric manifestations (sudden behavioral changes like abnormal hostility, hallucination, lapses of memory, severe depression); liver or kidney damage; or retinal changes and weakness.
"I believe the undiagnosed falciparum is causing immune suppression that predisposes patients to other infections," said Dr D''Costa. He said most doctors treat patients from the perspective of their narrow specialities, not recognising symptoms attributable to falciparum malaria. "I am confident that if we conduct collaborative studies on various hospital patients suffering from a variety of diseases, we could find that malaria is the underlying cause," he said.