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Clinical Case Study 2

(contributed by Prof. Jacques Le Bras, Hôpital Bichat - Claude Bernard, Paris, France)

A 30 year-old woman, HIV-positive, delivers by planned cesarean section an apparently normal female baby, weight 3.2 kg (7 lbs). At delivery AZT is administered IV for 7 hours. The mother is a native of the Democratic Republic of Congo (DRC) who came to France 2 years ago and has not traveled outside France since then. The only abnormality found in the baby at delivery is an anemia (12.3 g/dL hemoglobin) attributed to antiretroviral drugs toxicity (ARV given to mother?)

At 6 weeks post-delivery, the infant is brought in for a fever of one-day duration. She is found to have a temperature of 38.5°C and both hepatomegaly (3 cm) and splenomegaly (3 cm). Serologic tests for HBs and HCV are negative, and PCR, DNA and RNA for HIV are negative. More routine laboratory exams show: hemoglobin 6.4 g/dL, platelets 122,000/µL, LDH 1080 IU/mL, and blood smears showing the following:

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Question 1. What is your diagnosis?

• No malaria
• Plasmodium falciparum
• Plasmodium vivax
• Plasmodium ovale
• Plasmodium malariae
• Mixed infection (several Plasmodium species)

A transfusion of 125 mLs of blood (serologically negative for CMV) is given to the child.

Question 2. What antimalarial drug would you administer to the infant?

• Chloroquine
• Quinine-Doxycycline
• Mefloquine
• Halofantrine
• Primaquine

Following treatment with the orally administered antimalarial drug, parasitemia drops to 1% by day 3. At day 7, some parasite remnants are found and the child is afebrile. Drug testing in vitro of the parasite shows it to be sensitive to chloroquine.

Question 3. What test(s) would you perform to confirm current infection of the mother?

• Thin blood smear
• Thick blood smear
• PCR for malaria
• Serology

A thick blood smear of the mother, taken 5 days after that of the infant, is indeed positive, while on the thin smear no parasites can be detected.

Main Points

1. Congenital malaria should be considered in febrile newborns and infants from women who could have been parasitemic during their pregnancy.
2. Malaria parasitemia during pregnancy can result because the mother became infected during her pregnancy, but it can also result from an infection acquired months or years before.
3. The woman in this case probably was infected in DR Congo more than 2 years before delivery. Untreated Plasmodium malariae infection can persist >40 years and remain relatively asymptomatic.
4. Plasmodium vivax and P. ovale can similarly cause malaria several months or years after the original infection, by reactivation of dormant liver stage parasites.
5. Diagnostic procedures for detecting active malaria infection are, in order of increasing sensitivity: thin blood smear, thick blood smear, and PCR. Serology does not detect active infection, but measures past (and current) experience with malaria.

See Congenital Malaria as a Result of Plasmodium malariae - North Carolina, 2000.