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Unusual Presentation of Falciparum Malaria as generalized Anxiety Disorder at DHQTH Bannu Abdul Majid et al

• Ann. Pak. Inst. Med. Sci. 2011; 7(1): 26-28

26

Original Article

Unusual Presentation of Falciparum Malaria as generalized Anxiety Disorder at DHQTH Bannu

Background: Falciparum Malaria is the most serious and dangerous type of malaria. Patients with Falciparum Malaria may not be apparently seriously ill but may develop serious complications. Falciparum Malaria differs from all other types of malaria, in its severity and diverse clinical presentation. Objective: This study was carried out to present the unusual presentation of Falciparum Malaria in the form of generalized anxiety disorder. Place and duration of study: This study was carried out in the medical OPD of DHQTH Bannu NWFP from March 2005 to March 2007. Sampling Technique: Convenient sampling. Inclusive Criteria: All patients presenting with symptoms and signs of generalized anxiety disorder and found positive for Plasmodium falciparum (P.F.) were included in the study. Exclusion Criteria: 1. Those patients found positive for P.F. but presenting with other symptoms

• f P.F. malaria.
• 2. Those patients already suffering from anxiety disorder or other psychiatric illness.

Limitations of the study: Only the patients attending the Medical OPD of DHQTH of Bannu, during the years from 2005 to 2007 were included. Material and Methods: A total of 2300 patients of both sexes and above the age of 15 years were included in the study. Only those patients with symptoms of generalized anxiety disorder and found positive for the asexual forms of P.F. in the peripheral blood were included in the study. A detailed Performa was completed from all patients. Results: Out of 2300 patients, 253(11%) were found positive for P.F. Out of 253 patients, 39(15.5%) were males and 214(84.5%) were females. Seven (3.2%) females were pregnant. The common presentations of patients were headache, palpitation, insomnia and epigastric pain. Conclusion: This study reveals that Plasmodium falciparum can present with rare clinical features which need to be further evaluated. Due attention should be given to all the patients while recording their clinical history and all patients with vague symptoms should not be just labeled as neurotic or hysterical. Key Words: Plasmodium falciparum, Anxiety Disorder. Abdul Majid* Mohammad Shoaib Khan**

• Ch. Mohammad Fiaz***

Department of Medicine, Bannu Medical College, & Khalifa Gulnawaz Teaching Hospital, Bannu, NWFP *Department of Biochemistry, Bannu Medical College & Khalifa Gulnawaz Teaching Hospital, Bannu, NWFP. ***Department of Pathology, Pakistan Institute of Medical Sciences, Islamabad Address for Correspondence Dr, Mohammad Shoaib Khan Associate Professor &Khalifa Gulnawaz Teaching Hospital Bannu Medical College, Bannu

Introduction

Malaria is

• ne
• f

the most important communicable parasitic disease which is caused by bite

• f infected female Anopheles mosquito, though it can

also be acquired by use of contaminated syringes, through blood transfusion or transplacental route 1,2,3.It is a major public health problem throughout the world especially developing countries including Pakistan. The Roll Back Malaria (RBM) programme was started in Pakistan in 1998. According to this programme, malaria affects 300-500 million people each year and up to 3 million deaths per year globally 4. In Pakistan, malaria affects the low socioeconomic groups which constitute about 40% of the total population, especially in the southern and northern districts of NWFP Plasmodium falciparum is the most serious type of all four types of malaria because of its fatal complications 5.That is why delay in the treatment

• f Falciparum malaria may lead to serious and fatal

consequences6.

Unusual Presentation of Falciparum Malaria as generalized Anxiety Disorder at DHQTH Bannu Abdul Majid et al

• Ann. Pak. Inst. Med. Sci. 2011; 7(1): 26-28

27

At present, the prevalence of Falciparum Malaria is on rise and accounts for almost 18-62% of all cases of malaria in various regions of Pakistan with resistance to one or more anti malarial drugs 7, 8. The increasing prevalence of malaria in Pakistan may be due to the influx of Afghan refugees especially in NWFP and Balochistan, uncontrolled urbanization, uncontrolled population growth rate and environmental changes due to draughts, heavy rains, earth quakes, floods, and water development projects9. Plasmodium falciparum malaria is unique among other types of malaria because of its severity and diversity in clinical presentation 10, 11, 12. The aim of out study was to present the unusual presentation of Falciparum Malaria in the form

• f generalized Anxiety Disorder.

Material and Methods

This study was conducted in the outpatient department (OPD) of DHQ teaching hospital Bannu from March 2005 to March 2007. A total of 2300 patients of both sexes and above the age of 15 years were included in the study. All the patients were screened for Plasmodium falciparum malaria by thin and thick smears. The inclusion criteria was only those patients who presented with symptoms of generalized Anxiety Disorder and were found positive for asexual forms of Plasmodium falciparum. Those patients who were found positive for Plasmodium falciparum but who presented with other symptoms of Plasmodium falciparum malaria or those who were already suffering from anxiety or other psychiatric problems were excluded from the study. A detailed performa consisting

• f name, age, sex, address, occupation, detailed

clinical history, examination and relevant investigations was prepared and completed from each patient.

Results

Out of 2300 patients, who presented with symptoms of generalized anxiety disorder, 500(21.7%) were males and 1800(78.3%) were females. Out of the total patients screened, 253(11%) were found positive for Plasmodium falciparum. Out of these 253 patients, 39(15.5%) were males and 214(84.5%) were females. Seven (3.2%) patients were pregnant. Age range of the patients was 15-55 years with peak incidence of Plasmodium falciparum in the age range of 36-45 years. The most important presenting symptoms of the patients in our study were headache (28.4%), palpitation (24.5%) and insomnia (21.7%) especially in female patients (84.5%). The age/sex wise distribution

• f patients is shown in table I where as the symptoms

and sex wise distribution is shown in table II.

Table I: Age and Sex wise distribution of 253 P.F. positive patients

Age (years) Males Females Total 15-25 8(3.1%) 55(21.7%) 63(24.9%) 26-35 10(3.9%) 68(26.8%) 78(30.8%) 36-45 14(5.5%) 75(29.6%) 89(35.1%) 46-55 7(2.7%) 16(6.3%) 23(9.0%) Total 39(15.5%) 214(84.5%) 253(100%)

Table II: Symptoms/ Sex wise distribution

• f 253 P.F. positive patients

Symptoms Males Females Total Headache 10(25.6%) 62(28.9%) 72(28.4%) Palpitation 8(20.5%) 54(25.2%) 62(24.5%) Insomnia 8(20.5%) 47(21.9%) 55(21.5%) Epigastric Pain 7(17.9%) 22(10.2%) 29(11.4%) Nausea 2(5.1%) 10(4.6%) 12(4.7%) Irritability 2(5.1%) 8(3.7%) 10(3.9%) Difficulty Concentrating 1(2.5%) 8(3.7%) 9(3.5%) Near Syncope 1(2.5%) 3(1.47%) 4(1.5%) Total 39(15.5%) 214(84.5%) 253(100%)

Discussion

Detail review of the literature shows that Plasmodium falciparum malaria can present with wide variety of clinical features. It can present with Jaundice, hepatitis, permanent hepatic failure and even hepatic coma13-16, symptoms and signs suggestive

• f

gastrointestinal involvement in the form vomiting, diarrhea, abdominal pain, acute gastro enteritis, acute pancreatitis 11,14. CNS involvement can occur in the form

• f cerebral malaria, headache, altered conscious level,

seizures and signs of meningism 11,17,18. Plasmodium falciparum malaria may present in the form of sever anemia, leukemoid reaction, bleeding tendency, epistaxis and even disseminated intravascular coagulation.10, 12, 14, 16 It can present with hamaturia, black water fever, uremia and acute renal failure.10,11,16 Respiratory system may be affected by P.F. malaria in the form of pulmonary edema and Adult respiratory distress syndrome (ARDS), 14, 17. P.F can present as placental malaria 3 in which the peripheral blood smear is negative for Plasmodium falciparum but placental biopsy specimen on histology shows Plasmodium falciparum. After thorough study of the national and international literature on clinical presentation of P.F malaria, I was unable to find the clinical features which the patients in our study were presenting with. This study on unusual presentation of P.F malaria was

Unusual Presentation of Falciparum Malaria as generalized Anxiety Disorder at DHQTH Bannu Abdul Majid et al

• Ann. Pak. Inst. Med. Sci. 2011; 7(1): 26-28

28

started because while examining patients in the OPD o f DHQTH Bannu, several patients, especially females were complaining of symptoms and signs suggestive of generalized anxiety disorder (GAD) but showing no improvement with treatment by psychiatrist. During routine investigations of some of these patients, P.F was found positive and after treatment with oral arthemether + lumefantrin (Artem DS plus) patient showed dramatic response in improvement of symptoms. Later on a detailed performa was prepared and completed from all patients with symptoms of GAD and positive for P.F. malaria. Psychiatrist opinion was sought for each patient and only symptomatic treatment of symptoms of GAD was advised. All the positive cases in

• ur study were treated with oral Artem DS plus

(Artemether + lumefantrin) (40/240) tablets in a dose of

• 2tab. Stat, 2 after 8 hours, 2 after 24 hours and 2 after

48 hours. The medicines were provided free of cost from physician sample. The response to this treatment was good in all of our patients in the form of alleviations of symptoms and negativity of slides for P.F malaria. No side affects were noted in any patient.

Conclusion

This study reveals that the unusual presentation of P.F malaria as symptoms of GAD in our study, is not comparable with the review of national or international literature. But this rare presentation of P.F malaria in our study need due attention and highlights the importance of the fact that all patients presenting with vague symptoms, should not be labeled as neurotic or hysterical, but first of all, the organic causes must be excluded. Moreover especially in our backward set up, where almost 100% of the female patients are presenting with one or more symptoms of anxiety or depression, must be carefully interrogated and managed accordingly.

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