Case of the Fortnight (Archived)
Case 2 (Dec 1st, 2004)
This is a blood smear of a 36 yr female who presented with spiking fever of almost 1 week duration. Her ESR was mildly elevated and HIV was negative. All images are Leishman stained and under oil.
Presented by Dr N Jayaram, AILM, Bangalore.
jayaram@anandlab.com
Case 2 SOFT Discussion.
The presence of malaria is obvious - plasmodium vivax. In addition some smears showed wavy thread like structures. Careful inspection shows accentuation of what we presumed to be the nuclear area. We could not convince ourselves that these are platelet strands, and hence suggested the possibility of Borrleiosis coexisting with malaria.
Discussion at patho-india group list:
Dr Jayaram: Congratulations to Dr. Kale for a bulls eye. Dr. Aamir Hussain made a query about Borrelia and I award it to him too.
Many have called it microfilaria but you will agree that the structure does not really match.
Some have called it ADULT FILARIAL WORM - My My!!!
Trypanosoma was the other diagnosis offered.
Dr CSBR Prasad: My impression of SOFT-2 case is Malaria caused by Pl.vivax. The filamentous forms shown in the slides are exflagellated microgametes, recognizable by their filamentous shape with smooth curves and the presence of nuclear material. Borrelia usually takes little bluish tinge and show little kinking. Nuclear material is not usualy seen. Finding exflagellated microgametes is usually by chance and when the blood is kept in the tube for a while before making smear and it should not be mistaken for Borrelia. Please see CDC parasitology Feb, 1999 case, in their monthly case archives.
Dr Sachin Kale: Wow ! Thats a great hit Dr. Prasad !
Those web CMEs do come in handy, dont they ?!
The images at CDC do look quite similar to the ones hosted at
telepathologyindia. And having one disease at a time is more likely than two at a time. So unless some other diagnostic test result proving
borrelia is available, this is one differential diagnosis, which will be difficult if not impossible to discard.
Dr Jayaram: I must thank Dr. Prasad for so lucidly explaining the structure of exflagellated microgametes of P vivax. This has been a learning process for me, and for all of us. That is the whole purpose of putting up cases for discussion.