Plasmodium falciparum malaria recrudescence occuring 2.5 years after leaving an endemic country
Berrevoets, M.A.H., Dofferhoff, A.S.M.
Voorzitter(s): prof.dr. J.W. de Fijter, Leiden & dr. P.J. de Vries, Hilversum
Locatie(s): Zaal 0.5
Categorie(ën):
Case report: A previously healthy 48-year-old man was admitted to the Canisius-Wilhelmina Hospital in Nijmegen, The Netherlands with a 5-day history of general malaise, fever, chills, profuse transpiration and diarrhea. Originally from Burkina-Faso, he immigrated to the Netherlands 8 years before presentation. The patient had not visited his homeland or any other malaria-endemic country in the previous 2,5 years. No recurrent fever episodes were noted during this period. The last time he took malaria prophylaxis was in 1997. There was no history of blood transfusions. No friends or relatives from Burkina Faso had visited him for the last two months.
Physical examination revealed a sick, icteric patient. He was alert and oriented. Body temperature was 36.8ºC, blood pressure 135/85 mmHg, pulse 90 beats/min. Oxygen saturation was 96% with a respiratory rate of 40/min. There was no rash or lymphadenopathy. Cardiac examination revealed normal heart sounds without murmurs. The lungs were clear to auscultation. There were no palpable abdominal masses, nor hepato- or splenomegaly. Neurologic examinations were normal.
Laboratory results were as follows: C-reactive protein 149 mg/l, haemoglobin 7,8 mmol/l, thrombocytes 14x109/l, leucocytes 9,1x109/l, lactate 4,9 mmol/l, glucosis 5,3 mmol/l, creatinine 184 mcmol/l, bilirubine 218 mcmol/l, lactate dehydrogenase 441 U/I, aspartate aminotransferase 69 U/l, alanine aminotransferase 56 U/l, alkaline phosphatase 99 U/l. HIV antigen/antibody test was negative.
Ultrasound of the abdomen showed an enlarged spleen of 17.5cm. The chest x-ray was normal. A blood smear was performed and showed ring-shaped trophozoites consistent with Plasmodium falciparum (PF) with a parasite density of 3.2% and the presence of schizonts. The rapid antigen detection test was positive.
The diagnosis of PF malaria was confirmed by real-time PCR. No other pathogens were identified.
The patient was admitted to the intensive care unit because of tachypnea, acute renal failure and lactic acidosis. Treatment with intravenous artemisin was started and he recovered quickly. Parasite density was <0,1% after 24 hours treatment. By day 3 of treatment, no malarial parasites were seen and treatment was switched to oral atovaquon/proguanil. Follow-up was uneventful. Kidney function recovered completely and splenomegaly disappeared within 6 months.
Conclusion: This case illustrates the importance of malaria suspicion as a cause of illness in immigrants from malaria-endemic countries. Even when these immigrants did not travel for a long time, malaria should be considered in patients with typical symptoms.