Case 1

24 members have replied with their diagnosis. The following is the breakup:

Mixed PV + PF: 11
PF: 8
Babesiosis:3
P Malarie or PV: 1
Kalazar:1

This is an unique case of MULTIPLE INVASION OF ERYTHROCYTES BY PLASMODIUM VIVAX, a very unusual occurrence. The usual morphological means to distinguish PF from PV trophozoite forms are

1. Chromatin Dot: Toward the periphery in PF; towards the Centre in PV 2. Double Chromatin dot: In PF; not in PV 3. RBC size: Normal in PF; Increased in PV 4. Trophozoite size: Small in PF(1/6th RBC size) in PF; Large in PV (1/3rd size of RBC)

This patient is a very good friend of mine who unfortunately got infected while in Kolkatta. Since she was my friend, I was extra careful in reporting the type of malaria. The Paracheck Test for PF (Orchid) based on the detection of the presence of Pf HPR-2 was Negative. And the OptiMAL Test (DiaMed) based on the principal of indicator tagged mouse monoclonal antibodies to pLDH was positive for PV only.

Multiple infection of erythrocytes by PV is a rare occurrence. P Dutta(1) et al reported a case with mixed PF and PV with multiple infection of RBC's with PV only. In Malaya (2) a 16 day old infant multiple infection upto 3 parasites of PV has been reported. DasGupta BM al reported multiple infections (5 parasites in a single RBC) of PV (3). Cases having heavy multiple infections by PV parasite upto 8 rings have also been reported .

In our case SOFT case 1 we could demonstrate 3 parasites in 1 RBC (Image 3, the p'graph could have been better). The maraliologist Mr B K Goswami in RMRC(ICMR) Dibrugarh saw the slide and confirmed it to be PLASMODIUM VIVAX only and also some parasites outside the RBC's (which I could not demonstrate).

The cause of this rare phenomenon is unknown (4). Is it an inherent property of the parasite strain or a result of some host related factors?

References:
1. Dutta P, Goswami BK, Mahanta J. Multiple Invasion of Erythrocytes by Plasmodium Vivax- A Case Report: Ind J Haemat & Blood Transf 1997: Vol 15: No 3;38-9

2. Field JW and Niven JC. Anomalies in the Morphology of Plasmodium Vivax. Ind Med. Gaz.1939; 74(8); 5509

3. Dasgupta BM. Some anomalies in the morphology of PV occurring in a new born baby. Ind. Med Gaz 1939; 74(5). 273-274

4. Chowdhary DS, Ghosh SK, and U Devi C. Multiple Invasion of Erythrocytes by Plasmodium Vivax: A report of 56 cases. Indian J Malariol 1982: 101-108

Thanks to all of you namely Rashmi Patnaik, M Neelamani, Neha Dehiya, Ajay Junnarkar, Dilip Ramrakhiani, Parvin KU, Ramdas, Ahash Chhabra, Sanjay Bedi, CSBR Prasad, Shivaprakash N, Chandrasekhar J, NH Sarma, Shrinivasan, RK Krishnan, S. Agarwal, Deepika Sirohi, A Hussain, Sushama Patil, Utpal Goswami, Sopai Tawsik, K Singh, Atul Kapila, Sachin Kale for taking part and replying to this SOFT Case 1.