As compared to falciparum malaria, the less dramatic vivax malaria was often considered benign with fewer variations. We report a case of vivax malaria in a two month old with autoimmune hemolytic anemia.

A 2 month old girl was brought to our for fever with chills and rigors for 8 days and vomiting since 2 days. Systemic examination revealed a tachycardia of 142/min, severe pallor and a hepatosplenomegaly with a liver size of 4 cm below the costal margin [span of 8 cm], a soft consistency, nontender with a soft spleen that was 6 cm below the costal margin. With a concern that we may be dealing with falciparum malaria, the child was empirically started on intravenous artesunate. She had a hemoglobin of 8 g/dL 6 days before admission which had dropped to 5.2 g/dL 1 day before being hospitalized. Her hemoglobin on admission at our hospital was 4.1 g/dL with the peripheral smear revealing plasmodium vivax [few trophozoites, schizonts and gametocytes]. Initial reticulocyte count was 9.2% and LDH was 1405. In view of the rapid drop in hemoglobin, we asked for a direct Coombs test which was strongly positive. The first transfusion of packed cells raised her hemoglobin to 6.5 g/dL in a few hours while the second transfusion raised it to 8.4 g/dL. We omitted artesunate as soon as the smear report was available and initiated the child on oral chloroquine followed by primaquine once the G6PD report was normal. Subsequently, her hemoglobin stabilized at 8.8 g/dL by the 8th day. DCT became negative and the reticulocyte count also dropped [2.6%]. While AIHA is occasionally seen with falciparum malaria [1,2], there are only occasional reports of vivax induced AIHA in the world literature [3]. Thrombocytopenia which was once considered an indicator of falciparum malaria is now routinely seen with vivax malaria, albeit with a much more benign course. When faced with dropping hemoglobin in a patient with vivax malaria, the first thought that comes to mind is parasite induced destruction of red blood cells causing rapid drop in hemoglobin or drug induced hemolysis in a G6PD deficient individual. However, we must include rarer causes of drop in hemoglobin such as infection induced hemophagocytic syndrome [4] and a AIHA caused by the malarial parasite.

Such an AIHA can also be suspected when it is almost impossible to cross match blood [did not occur in our case]. Malaria induced AIHA is usually self-limiting and abates once the primary disease is treated.

1. Ritter K, Thomssen R, Kuhlencord A, Bommer W. Prolonged haemolytic anaemia in malaria and autoantibodies against triosephosphate isomerase. Lancet. 1993;342:13-4.

2. Facer CA, Bray RS, Brown J. Direct Coombs antiglobulin reactions in Gambian children with Plasmodium falciparum malaria: I. Incidence and class specificity. Clin Exp Immunol. 1979;35:119-27.

3. Sitalakshmi S, Srikrshna A, Delvi S, Damodar P, Mathew T, et al. Changing trends in malaria—a decade’s experience at a reference hospital. Indian J Pathol Microbiol. 2003;46:399-401.

4. Sanklecha M, Mehta N, Baghban H. Varied presentations of complicated falciparum malaria in a family. Indian Pediatr. In press. 2011.