Indian Journal of Dermatology
CORRESPONDENCE
Year
: 2022  |  Volume : 67  |  Issue : 4  |  Page : 444--446

Reticulated erythema and urticaria: Rare cutaneous manifestations during malaria


Fatima-Zahra Agharbi, Soumiya Chiheb 
 From the Department of Dermatology, Sheikh Khalifa Hospital, Faculty of Medicine, Mohamed VI University of Health Sciences, Casablanca, Morocco

Correspondence Address:
Fatima-Zahra Agharbi
From the Department of Dermatology, Sheikh Khalifa Hospital, Faculty of Medicine, Mohamed VI University of Health Sciences, Casablanca
Morocco




How to cite this article:
Agharbi FZ, Chiheb S. Reticulated erythema and urticaria: Rare cutaneous manifestations during malaria.Indian J Dermatol 2022;67:444-446


How to cite this URL:
Agharbi FZ, Chiheb S. Reticulated erythema and urticaria: Rare cutaneous manifestations during malaria. Indian J Dermatol [serial online] 2022 [cited 2023 Feb 6 ];67:444-446
Available from: https://www.e-ijd.org/text.asp?2022/67/4/444/360321


Full Text



Sir,

Malaria is a major public health problem worldwide, and in developing countries in particular. The disease is still endemic in several parts of Africa, especially in sub-Saharan regions. Cutaneous lesions in malaria are not specific and rare. Cases of urticaria, angioedema, petechiae, reticulated erythema, purpura and disseminated intravascular coagulation (DIC) due to Plasmodium falciparum malaria and P. vivax malaria have been reported in the literature.

We report a case of malaria with reticulated erythema and urticaria in a 20-year-old patient.

A 20-year-old woman presented with an acute febrile skin rash. Cutaneous examination revealed reticulated erythema of the trunk with urticarial lesions of the arms [Figure 1]. Lesions were mildly itchy. There was no history of drugs in the last 4 weeks; however, the patient had travelled to Senegal a month ago. The nasopharyngeal swab test for SARS-CoV-2 RNA amplification was negative. On investigation, blood count, hemogram and liver function were within the normal range. A peripheral smear showed trophozoites of P. falciparum. The patient was treated with chloroquine along with antihistamine with good evolution.{Figure 1}

Malaria is caused by parasites of the genus Plasmodium transmitted to humans by the bites of infected female mosquitoes of the Anopheles species, called “vectors of malaria”. There are five species of parasites that cause malaria in humans, of which two—P. falciparum and P. vivax—are the most dangerous. The major complications of severe P. falciparum malaria include cerebral malaria, pulmonary oedema, acute kidney injury, severe anaemia, acidosis, hypoglycaemia, and DIC.[1] These complications can develop rapidly and progress to death within hours or days. Many of these complications are believed at least in part to be related to coagulopathy and microvascular changes in this disease. Cutaneous lesions in malaria are rarely reported and include urticaria, angioedema, petechiae, and purpura.[2],[3],[4],[5],[6] Exact pathogenesis of skin rash in malaria is not known, but these may reflect part of different immunological consequences during malarial infection. It seems that the mast cells play a central role in the pathophysiology of malaria.[7] In fact, mast cell activation and degranulation have been observed in the skin dermis of malaria patients. In addition, studies have shown that the number of mast cells and the degree of degranulation and IgE level correlate with parasitaemia and disease severity. The precise mechanism of mast cell activation in malaria is not known. There can be multiple mechanisms that activate the mast cells. Malaria antigens have been reported to activate macrophages and monocytes to produce various cytokines, such as tumour necrosis factor (TNF) alpha and interleukin-1 beta. These cytokines, which are classified as mast cell secretagogues, may activate mast cells through FcεRI receptors with the secretion of IgE.[2]

Many features of malarial pathology like an increased expression of endothelial adhesion molecules (ICAM-1, VCAM-1, and E-selectin), increased vascular permeability and vasodilatation are mediated by mast-cell mediators such as histamine, serotonin, heparin, proteoglycans, certain proteases, prostaglandins, leukotrienes, platelet-activating factors and cytokines (TNF).

Vasculitis lesions have also been described with deposition of immune complexes containing IgG and IgE, resulting in extensive vascular damage to endothelial cells. IgE-containing immune complexes are associated with complicated malarial infections.[2],[7]

Skin lesions associated with malaria reflect the different immunopathological mechanisms in malarial infection. Urticaria and erythema are usually due to histamine and/or other mediators which explain their association in our patient. Purpura and petechiae may be a result of cytoadherence, local vasculitis and vessel damage.[2],[7]

The occurrence of erythema reticularis during malaria is rare. To the best of our knowledge, only two cases have been reported in the literature in association with petechiae in relation to P. falciparum malaria.[1] The association of erythema reticularis and urticaria as in our patient has never been reported in the literature.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Angchaisuksiri P. Coagulopathy in malaria. Thromb Res 2014;133:5-9.
2Vaishnani JB. Cutaneous findings in five cases of malaria. Indian J Dermatol Venereol Leprol 2011;77:110.
3Singh RP, Mittal SP, Narayanan VA, Shetty KJ. Occurrence of urticaria as a manifestation of Falciparum malaria. J Assoc Physicians India 1988;36:261-2.
4Maheshwari N, Maheshwari V, Mobashir M. Plasmodium vivax malaria presenting with urticaria (letter). Postgrad Med J 1989;65:266-7.
5Khaira A, Gupta V, Mahajan S, Bhowmik D, Tiwari SC. Purpura fulminans in a complicated Falciparum malaria. J Assoc Physicians India 2008;56:467-9.
6Sharma A, Sharma V. Purpura fulminans: An unusual complication of malaria. Braz J Infect Dis 2013;17:712-3.
7Wilainam P, Nintasen R, Viriyavejakul P. Mast cell activation in the skin of Plasmodium falciparum malaria patients. Malar J 2015;14:2-7.