Killer Mosquito

Medical case report Dr Farooq Haider Qaisrani

Presentation and History

Ali18 month old child present in emergency room with parents for new-onset seizures. According to mother 18 month old boy was in his normal state of health, when he complained of fever for 1 day , fever was high grade and continuous with shivering rigor and chills then in morning child developed a headache and fits.

Fit occurred in one episode and lasted for 3 minutes and was generalized tonic clonic, jerky movement of limbs and patient had frothing from mouth with uprolloing of eyeballs and loss of consciousness and no history of fecal and urinary incontinence.
Ali regained consciousness when they arrived at hospital.
Ali has had normal development. His family history is significant for a single seizure with fever that his father had at age 2 years.
Ali was born by spontaneous vaginal delivery , a healthy full-term baby. Vaginal delivery was uncomplicated, birth parameters above 50th percentile, with no prior serious health problems, and was meeting all developmental milestones. He was fully immunized as per epi , there was no history of regular medication and has no history of allergy.

Physical examination

Ali looked unwell, irritable and anxious, with no obvious dysmorphic features.

His heart rate was 122 bpm,

Respiratory rate 29 breaths/min, blood pressure 90/60 mm hg, and temperature
104°f . His blood sugar level was 135 mg/dl and spo2 97 %.
By the time the child arrived to the hospital, he was awake and he recognized his
Parents.

Anthropometric measures : weight 12 kg
Height 80 cm
Head circumference 47.5 cm
All in normal percentiles.

Systemic examination

Skin: no current or healing skin infection.

Cvs: acyanotic , pulses normal rate, rhytm, normal jvp, equal peripheral pulses,capillary return less than 3 sec, no oedema.apex beat normal, heart sound were normal.

Respiratory: normal air entry, no wheeze, rhonchi, crepitations, crackles, lung bases clear.

Git:abdomen soft non tender splenomegaly 2 cm below left costal margin with soft to firm consistency and notch palpable no other viscera palpable

Cns: fully conscious gcs was 15/15 fontanella seem to closed and there were no signs of meningeal irritation and babniski was negative , cranial nerve intact

Throat and muskoloskeletal was normal .

Differential diagnosis:

1.Simple Febrile seizure [most likely due to malaria]

2.Meningitis

3.Encephalitis

Investigations:

Following investigations were performed on the basis of differential diagnosis:

Cbc
Random blood sugar
Csf routine examination
Serum calcium, magnesium, phosphorous
Complete urine examination
Ict malaria, malaria slide

Reports came back positive for malarial parasite with Plasmodium Falciparum on Malarial slide, cbc showed anemia. His hb was 8.9 g/dl ( normal range is 12-16 g/dl), electrolytes and other labs came back normal.

Final diagnosis and management:

Ali was diagnosed with simple febrile seizure because of malaria. Patient was started on iv paracetamol, inj artesunate 2.4 mg/kd/dose at 0, 12, 24 hour and inj ceftrixone 50mg/kg/day. 1

On his arrival his parents were very concerned about his health and episode of fits.
His mother was very worried about the fever however he remained afebrile for next 24 hours and was then discharged.
His mother was counselled about the disease and guided about use of anti pyretics and role of sponging in order to control fever.
He was diagnosed as a case of simple febrile seizure because of malaria.
He was discharged later and was guided about oral iron therapy and his mother was guided about role of iron deficiency in febrile seizure. She was also told about use of rectal diazepam suppository incase if seizure episode happens again.
His mother was also guided about preventive measures about malaria, how to avoid mosquites and use of mosquito nets and sprays.

Discussion and Summary :

Ali was suffering from simple febrile seizure because of malaria.

Febrile seizures are convulsions or seizures in infants between age of 3 months and 60 months.they can be classified into following types: 2

Simple febrile seizure :

duration of seizures is less than 15 min and it is normally slef -limiting, generalized tonic clonic in nature and there is no recurrence in 24 hours and there is no post-ictial pathology.

Complex febrile seizure :

duration is greater than 15 min and may be followed by febrile status epileptics ( >30 min), focal onset, loss of muscle tone, there may be recurrence in 24 hours and there may be post-ictial pathology.

Patient was suffering from simple febrile seizure and his mother was told about the risk factors that are male, positive family history, iron deficiency anemia.

Preventive measures that can be taken to avoid mosquito as guided by NHS UK are :

Protection by mosquito bites.
Mosquito sprays.
Controlling mosquito breading places .
Covering arms and legs. 4

Unfortunately Ali came from desert area of Multan, where there is poor hygiene system, with not properly developed sewerage system so misquotes breeding places are in frequent number and no proper medical system. His mother was explained about every precaution possible to avoid such an episode again and also how to avoid mosquito.
After this patient, doctors from QMC Multan are visiting these areas on regular basis and guiding local dispensers and people about potential killer disease malaria.

References:

1. Nelson textbook of pediatrics. 22nd edition.
2. Www.healio.com/pediatrics/journels Pediatrics annals december 2013-vol 42-issue 12
3. Iranian journel of child neurology. Iran j child neurol :2014 spring:8(2): 38-44
4. www.nhs.uk/conditions/malaria/pages/prevention

By: Qaisrani