Congenital Malaria --- Nassau County, New York, 2004
Human malaria is a parasitic disease caused by four distinct species of intraerythrocytic protozoa of the genus Plasmodium. The parasites are transmitted to persons by the bite of an infective female Anopheles mosquito and rarely through blood transfusion and congenital transmission (1,2). The majority of malarial infections reported in the United States are acquired abroad by recent immigrants or persons returning from areas where malaria is endemic (3,4). This report describes the first documented case of congenital malaria acquired in Nassau County, New York, which is the fifth case of congenital malaria reported in the United States since 2000 (5--8). Health-care providers should consider malaria as a diagnosis in neonates and young infants, particularly those with fever, whose mothers emigrated from areas where malaria is endemic.
In April 2004, a previously well male infant aged 7 weeks born in Nassau County was hospitalized with a 1-day history of low-grade fever. The infant had been born at full term in an uncomplicated vaginal delivery; birthweight was 6 pounds, 14 ounces, and his APGAR scores were 9/9 (out of 10, at 1 minute and 5 minutes after birth). On admission to the hospital, the infant was placed on antibiotic treatment, and a laboratory evaluation was performed for a presumptive diagnosis of sepsis by using bacterial cultures of blood, urine, and cerebrospinal fluid (CSF) and viral cultures of CSF; however, the cultures yielded negative results, and no cause was identified. On the third day of hospitalization, antibiotics were discontinued, the infant had no fever, and he was discharged. Laboratory testing indicated hemoglobin of 9.2 g/dL (normal: 10.0 g/dL--14.3 g/dL) and a white blood cell count of 6,300 cells/µL (normal: 6,000 cells/µL--17,500 cells/µL).
On follow-up 5 days after discharge, the infant had no symptoms or signs of illness except for a hemoglobin measurement of 6.2 g/dL with a hematocrit of 18% (normal: 29.3%--42.2%). Peripheral smears revealed malarial parasites (parasitemia <1% of red blood cells); morphology was consistent with Plasmodium vivax. The infant was immediately readmitted to the hospital. Treatment with the recommended dose of chloroquine was well tolerated, and the infant was transfused with 75 mL (15 mL/kg of patient body weight) of packed red blood cells before discharge. His hemoglobin at discharge was 11 g/dL, and he had negative smears for malarial parasites.
Investigation by the Nassau County Department of Health revealed that the mother had emigrated from Guatemala in June 2003 and since then had not traveled outside the United States. The risk assessment questionnaire used by her prenatal provider did not include a question regarding history of malaria. In November 2003, during her fifth month of pregnancy, the mother telephoned her health-care provider to report a 1-day history of fever, myalgia, and headache. Two days later, she went to a local emergency department with headache, sore throat, and rhinorrhea. She was discharged with a diagnosis of upper respiratory infection. No laboratory or other studies were performed.
After malaria was diagnosed in the infant, blood was collected from the mother the same day; the sample was negative for malarial parasites on blood films but positive for P. vivax DNA by polymerase chain reaction. She was prescribed chloroquine and primaquine. One month later, the mother was interviewed in Spanish, her native language; she stated that she had malaria diagnosed 2 years earlier in Guatemala and was treated with an unknown therapy. She told interviewers she had one relapse while residing in Guatemala. She could not recall the date of her relapse, nor the type of treatment.
Reported by: B Doraiswamy, MD, Nassau Univ Medical Center, East Meadow; A Genovese-Candela, MBA, Nassau County Dept of Health, Mineola, New York.
Malarial infection or relapse during pregnancy poses substantial risks to the mother and fetus, including risks for maternal anemia, spontaneous abortion, perinatal mortality, low birthweight, and prematurity (1,3). Pregnancy is known to be a common cause of relapse with P. vivax and P. ovale (4). Recurrences of any partially or improperly treated species of Plasmodium might be caused by the natural immune suppression that is characteristic of pregnancy (8). Diagnosis can be complicated by the nonspecific clinical presentation of this disease (1,4). Practitioners in areas where malaria is not endemic often fail to consider malaria in their initial differential diagnoses (9). In an immigrant, diagnosis of malaria is further complicated because many immigrants have partial immunity, possibly resulting in longer incubation periods and more subtle, nonspecific symptoms (1). In a newborn, signs and symptoms of malaria, including fever, poor appetite, irritability, and lethargy, can mimic sepsis, further obscuring the diagnosis (3).
According to the Pan American Health Organization, malaria remains endemic in 21 countries of the Americas, including Guatemala, the country of origin for the mother described in this report. P. vivax is the predominant malarious parasite in the Americas, accounting for 71% of cases in the 21 countries with transmission and 97% of cases in Guatemala in 2001 (10).
Practitioners should ask immigrant patients their country of origin, date of immigration, and dates of any return travel to their home country (4). Practitioners should also be aware of information resources regarding the global distribution of infectious diseases of clinical importance (http://www.cdc.gov/travel). In the rare case of congenital transmission described in this report, language and cultural barriers might have posed obstacles to disclosure by the pregnant mother of her history of malaria to her health-care provider. When feasible, medical history forms completed by a patient in any health-care setting should be available in the patient's native language and should include conditions and diseases of epidemiologic importance. CDC recommends that malaria be considered in the differential diagnosis of illness in 1) persons with fever and a history of travel to areas where malaria is endemic, including immigrants, refugees, migrant laborers, and international travelers; 2) fever of unknown origin, regardless of travel history; and 3) ill neonates and young infants, particularly those with fever and immigrant mothers, regardless of the interval between the mother's immigration and delivery (2,8). Additional information regarding diagnosis of malaria is available at http://www.dpd.cdc.gov/dpdx.
The findings in this report are based, in part, on contributions by A Greenberg, MD, D Kuhles, MD, M Sherman, C Cabello, MPH, Nassau County Dept of Health, Mineola; M Anand, MPH, J Ennis, A Teal, B Wallace, MD, P Smith, MD, New York State Dept of Health.
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