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Mixed Malarial Infection with Pancytopenia in a Child with Acute Lymphoblastic Leukemia: An Unusual Presentation

© 2017 Indian Journal of Medical and Paediatric Oncology | Published by Wolters Kluwer Medknow Sir, A coinfection with Plasmodium vivax and Plasmodium falciparum complicating a hematological malignancy in a child has rarely been reported. We present a child with underlying acute leukemia who had mixed malarial infection at presentation. An 18‐month‐old male child presented with intermittent high‐grade fever with no localizing symptoms of 2‐month duration. On examination, the child had pallor and firm splenohepatomegaly. There were no clinical bleeds or significant lymphadenopathy or bone tenderness. Complete blood count showed pancytopenia (Total Count (TC) – 1800 cells/cumm, P18 L80 M2, Hb – 5.7 g/dl, platelet count – 46,000 cells/ cumm). Peripheral smear showed numerous ring forms and trophozoites of P. vivax and P. falciparum. Child was treated with artesunate combination therapy and primaquine. There was good response to antimalarial, child became afebrile and organomegaly regressed in size. Repeat smear for malarial parasite was negative. On follow‐up after 2 weeks, there was recurrence of fever and laboratories showed persisting pancytopenia (TC – 2700 cells/cumm, P15 L82 M3, Hb – 6 g/dl, platelet count – 30,000 cells/cumm). The possibility of hemophagocytosis secondary to malaria or an underlying lymphoreticular malignancy was considered and further evaluation was done. Erythrocyte sedimentation rate was high (112 mm/h) and lactate dehydrogenase was elevated (871 U/L). Bone marrow aspirate showed aparticulate dilute marrow with absent megakaryocytes, 12% atypical lymphoid cells, no evidence of hemophagocytosis. Bone marrow biopsy showed abnormal blastoid cells with vacuolated cytoplasm and round vesicular nuclei with inconspicuous nucleoli, consistent with acute leukemia. Bone marrow flow cytometry confirmed CALLA‐positive B‐cell acute lymphoblastic leukemia. Child is currently on maintenance chemotherapy and is doing well.