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Malaria in an Immigrant and Travelers -- Georgia, Vermont, and Tennessee, 1996Each year, approximately 1000 cases of malaria are reported in the United States, nearly all among persons with histories of antecedent international travel. Failure to use appropriate measures to prevent infection when traveling in areas with endemic disease and delays in diagnosis and treatment can result in severe complications and death. This report presents three recent cases of malaria that illustrate the importance of following the fundamental measures for preventing malaria. Case 1 In November 1996, a 37-year-old woman who was 35 weeks' pregnant was admitted to a hospital in Atlanta, Georgia, because of a 3-day history of fever, chills, dysuria, back pain, nausea, vomiting, and headache. She denied cough, night sweats, and weight loss. She had moved to Georgia from Honduras in 1994 and had not traveled outside the United States since arriving. On physical examination, her temperature was 102.2 F (39.0 C), and she had a firm gravid uterus. Laboratory findings included a hematocrit of 30% (normal: 34%-46%); white blood cell (WBC) count, 4400/mm3 (normal: 4300-10,800/mm3); and serum glucose, 203 mg/dL. Urinalysis showed 1+ protein, 3+ glucose, 2-5 WBCs, and two red blood cells (RBCs). She was admitted to the hospital with a diagnosis of a possible urinary tract infection and/or meningitis; following a lumbar puncture (analysis within normal limits) empirical treatment with cefazolin was initiated. However, her fever persisted and, on the fifth day of hospitalization, intraerythrocytic parasites consistent with malaria were detected in a peripheral blood smear. Based on her move from Honduras in 1994 and microscopic examination of her blood smear, Plasmodium vivax infection was diagnosed; treatment was initiated with chloroquine 600 mg base PO, followed by 300 mg 6 hours later and daily for the next 2 days. She immediately defervesced and was discharged on chloroquine 300 mg weekly until delivery. Five weeks later and despite apparent gestational diabetes, she delivered a healthy baby without complications. She was prescribed primaquine 15 mg base PO for 14 days after finishing breast-feeding. Case 2. In October 1996, a 49-year-old man was admitted to a hospital in Vermont because of a 6-day history of nausea, vomiting, diarrhea, fever, and chills. Illness had begun 6 days earlier during a 5-week business trip to Kenya and southern Sudan. As a physician and an international health consultant, the patient had traveled frequently to areas with endemic malaria. In June 1996, he had had an episode of P. falciparum malaria and was treated with quinine. Although he had used chloroquine prophylaxis during previous travels, he had not taken any antimalarial drugs during the trip to Kenya and Sudan because of concerns with long-term chemoprophylaxis toxicity. During the trip, he had noticed a foot ulcer and had cleaned the wound. Two days before departing for return to the United States, he had acute onset of vomiting, diarrhea, and fever, but initially attributed these symptoms to food poisoning. When the fever persisted and diaphoresis and chills occurred, he considered the possibility of malaria but did not seek treatment. His condition improved, but during a 1-day stop while in transit to the United States, fever and fatigue recurred. He deferred medical evaluation until his return to Vermont, where he was admitted to the hospital. On physical examination, his temperature was 99.8 F (37.7 C), and blood pressure was 103/54 supine and 80/46 sitting. Laboratory findings included hemoglobin of 9.3; WBC count, 7400/mm3; platelets, 35,000/mm3 (normal: 150,000-450,000/mm3); blood urea nitrogen, 83; creatine, 3.7 mg/dL (normal: 0.8-1.3 mg/dL); total bilirubin, 1.8 mg/dL (normal: 0.2-1.5 mg/dL); and direct bilirubin, 1.4 mg/dL (normal: 0-0.4 mg/dL). Urinalysis showed 1+ protein and 1+ blood with granular casts and urate crystals. Examination of a blood smear detected P. falciparum parasites with a density of 1% of parasitized RBCs. Treatment was initiated with intravenous quinidine and doxycycline. On the third day of hospitalization, the patient developed adult respiratory distress syndrome, which required intubation for 1 week; complications included barotrauma, acute tubular necrosis, and a nosocomial infection. Concurrently, the patient was diagnosed with and treated for Entamoeba histolytica diarrhea and Staphylococcus aureus infection in the foot ulcer. He recovered fully after an 18-day hospitalization. Case 3 On March 25, 1996, a 64-year-old resident of Tennessee sought care at a local emergency department because of a 5-day history of intermittent fever, nausea, severe diarrhea, and generalized body aches. On March 20, he had returned from an annual trip to rural areas of Papua New Guinea, Philippines, and Myanmar, where malaria is endemic. During 18 previous trips, he had never taken malaria chemoprophylaxis, although he was aware of the recommendations for prophylaxis. Malaria was presumptively diagnosised, and he was admitted to the hospital. His temperature on admission was 100 F (38 C) and pulse rate was 111 beats per minute. Laboratory findings included a white blood cell count of 2900/mm3 (normal: 4300-10,800/mm3); platelet count, 58,000/mm3 (normal: 130,000-400,000/mm3); hematocrit, 44% (normal: 42%-52%); and total bilirubin, 1.2 mg/dL (normal: less than 1.6 mg/dL). Peripheral blood smears obtained during the first 2 days of hospitalization showed ring forms diagnostic of P. falciparum with less than 1% parasitemia. He was treated with oral quinine and doxycycline. On the night of admission, he sustained a respiratory arrest and was placed in the intensive-care unit (ICU) and was resuscitated. His antimalarial medication was changed to intravenous quinidine and doxycycline. On March 27, the quinidine was discontinued because of prolongation of the QT interval on his electrocardiogram. His condition improved, and antimalarial treatment was discontinued after 7 days. On April 2, the patient developed increasing respiratory difficulty and was transferred back to the ICU for suspected pulmonary edema and multilobar nosocomial pneumonia. Despite aggressive treatment, he died on April 6. Reported by: C del Rio, MD, S Edupuganti, MD, M Cassoobhoy, MD, Dept of Medicine, Emory Univ School of Medicine, Atlanta, Georgia. T Taylor, MD, F Ricaurte, MD, RP Mogielnicki, MD, Veterans Affairs Medical Center, White River Junction, Vermont. A Soufleris, MD, Infectious Diseases Section, Univ of Tennessee College of Medicine, Chattanooga; L Allen, J Beville, MD, Southeast Region, Tennessee Dept of Health, Chattanooga; W Moore, MD, State Epidemiologist, Communicable and Environmental Disease Svcs, Tennessee Dept of Health. Malaria Section, Epidemiology Br, Div of Parasitic Diseases, National Center for Infectious Diseases; Div of Applied Public Health Training (proposed), Epidemiology Program Office, CDC. Editorial NoteEditorial Note: Malaria remains a major cause of morbidity and mortality worldwide, with an estimated 300-500 million cases occurring annually (1). Factors associated with increased risks for or variations in the epidemiology of malaria include increasing international travel, changing patterns of travel (e.g., "adventure tourism" or immigration from malarious areas), and intensified antimalarial drug resistance (2). The first two cases described in this report underscore important considerations regarding recognizing and promptly treating malaria in U.S. citizens and others returning from abroad or who are visiting the United States. Prompt diagnosis requires that malaria be included in the differential diagnosis of illness in a febrile patient with a recent history of travel to an area with endemic disease. Because some patients may not spontaneously mention a travel history, clinicians should ask about recent travel, particularly when evaluating febrile illnesses in international travelers, immigrants, migrant laborers, and international visitors. The patient's travel itinerary can provide key information for choosing appropriate drugs for antimalarial prophylaxis and malaria treatment. For example, since relapses of P. vivax can occur up to 4 years after the initial infection, for case 1, history of having lived in Honduras 2 years before the onset of illness was relevant to considering malaria. The second and third cases illustrate the importance of antimalarial prophylaxis when traveling in a malarious area and the hazards associated with delaying diagnosis and treatment. Although malaria is most prevalent in rural areas of the tropics at elevations below 3282 feet (1000 meters), it is not limited to these areas. A careful review of a traveler's itinerary is necessary to determine the need for chemoprophylaxis and the most appropriate drug-treatment regimen. Prophylaxis should be started 1 week before travel (1-2 days for doxycycline) and continued throughout the stay in the malarious area and for 4 weeks after leaving the area. Although retinopathy has been reported after high doses of chloroquine for treatment of illnesses such as rheumatoid arthritis, this has not been documented to occur when chloroquine is used long-term for antimalarial prophylaxis. When malaria is suspected, diagnosis and treatment should be initiated immediately. P. falciparum malaria often presents with nonspecific symptoms without the classical periodic fever. Because the multiplication cycle for this species is only 36-48 hours, the patient's clinical condition can deteriorate rapidly and, as in case 2, a delay of even as little as 6 hours can be critical. The potential sequelae of untreated P. falciparum malaria (e.g., adult respiratory distress syndrome, cerebral malaria, and renal failure) can be life-threatening. In addition, the estimated median cost ($12,516) of treating one case of severe P. falciparum infection contrasts sharply to the relatively inexpensive cost of a full prophylactic course of mefloquine ($48.00 to $56.00 for a median-length trip of 23 days) (3). Information about malaria prophylaxis and treatment is available from CDC's Division of Parasitic Diseases, National Center for Infectious Diseases, telephone (770) 488-7760, from 8 a.m. to 4:30 p.m. eastern time, Monday through Friday, and (404) 639-2888 during other hours and on weekends. The automated information service (telephone {404} 332-4565) will fax documents containing information about general aspects of malaria, malaria in pregnant women and children, and prescription drugs used for malaria. International travel information is available on the World-Wide Web at http://www.cdc.gov/travel/travel.htm. References
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