Correspondence
Congenital Malaria
N Engl J Med 1997; 336:71-72January 2, 1997
- Article
To the Editor:
The legend accompanying the Image in Clinical Medicine of placental malaria (July 11 issue)1 states that the mother's red cells were infected but the baby's were not. My concern is that this is not always the case. Sometimes there are leakages between the mother's circulation and the baby's. I worked in Cameroon for nine years and saw a number of cases of congenital falciparum malaria. The babies present with respiratory distress and the rapid development of jaundice and hepatosplenomegaly. My colleagues and I saw about six such infants, and about half survived with rapid administration of quinine. The mothers were usually febrile, and some of the infants were preterm. I want to be sure that people do not automatically assume that the infants of mothers infected with falciparum malaria are born free of the disease.
1 ReferencesRosemary B. Lane, M.D., M.P.H.
224 W. Royal Dr., DeKalb, IL 601151
Miller IJ ,Telford SR III . Placental malaria. N Engl J Med 1996;335:98-98
Full Text | Web of Science | Medline
To the Editor:
Miller and Telford recently reported a case of placental malaria that was illustrated by a microscopical section of the placenta, showing parasites in the maternal space and sparing of the fetal erythrocytes. The infant was reportedly not ill. This report raises the question of the role of empirical or prophylactic treatment of the infant in such cases.
A 21-year-old Honduran woman who had immigrated to the United States nine months earlier gave birth to a female infant at 37 weeks' gestation. The mother had fever and thrombocytopenia; peripheral-blood smears revealed Plasmodium vivax malaria. Fever, hepatosplenomegaly, and anemia developed in the infant at four weeks of age; peripheral-blood smears showed parasitemia with P. vivax. The baby was successfully treated with chloroquine and a blood transfusion.
The incidence of congenital malaria in areas in which the disease is endemic is estimated to be less than 1 percent. In the United States approximately one or two cases are reported annually to the Centers for Disease Control and Prevention.1 Transmission of malaria to the fetus appears to be prevented in most cases by the major barrier of the placenta and by serologic immunity conferred by maternal antibodies. Although there have been no clinical trials, some authors recommend treating the infant presumptively if the mother has parasitemia at the time of delivery.1 Prospective, randomized studies of prophylactic treatment of infants would be useful in guiding practice.
1 ReferencesBarbara Edwards, M.D.
Mount Sinai Services at Queens Hospital Center, Jamaica, NY 114321
Zucker JR ,Campbell CC . Malaria: principles of prevention and treatment. Infect Dis Clin North Am 1993;7:547-567
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: We presented a photomicrograph of a malaria-infected placenta to demonstrate that florid parasitemia was present in the maternal blood space, whereas no parasites were found in the fetal villi. The fetus appears to be remarkably resistant to infection. This resistance may reflect, among other things, the physical barrier of the placenta and the poor environment afforded by fetal erythrocytes for plasmodial replication, due to their fetal hemoglobin composition1 and low free-oxygen tension. The prevailing view in the older literature was that malaria was a substantial risk factor for fetal growth retardation due to placental insufficiency, particularly in primigravidas.
The largest risk (protective) factor for perinatal and neonatal morbidity from malaria depends on the prevalence of malarial infection at the population level, which has been presumed, but not proved, to reflect the immune status of the individuals in the population. In a recent study of an area in which the disease was hyperendemic, McDermott et al. stated, “Placental malaria was not found to be significantly associated with stillbirth or with early neonatal death.” 2 Likewise, despite the recent observation that parasites can be detected in the cord blood of 35 percent of infants whose mothers have infected placentas,3 neonates in Africa rarely present with clinical disease, and “congenital malaria has been assumed to be of little clinical importance in areas of high malaria endemicity.”4 As Lane and Edwards point out, congenital malaria does occur, but its frequency depends on factors such as perinatal clearance of occult parasitemia, maternal immunity, and coexisting infections.
We agree that malaria in a nonimmune pregnant woman may sometimes have serious consequences for the fetus and that physicians must decide which treatments are appropriate in each case. At the population level, however, recent studies do not support the conclusion that congenital malaria is common and warrants a trial of chemoprophylaxis.
4 ReferencesIra J. Miller, M.D., Ph.D.
Dana–Farber Cancer Institute, Boston, MA 02115Sam Telford, D.Sc.
Harvard School of Public Health, Boston, MA 021151
Wilson RJ ,Pasvol G ,Weatherall DJ . Invasion and growth of Plasmodium falciparum in different types of human erythrocyte. Bull World Health Organ 1977;55:179-186
Web of Science | Medline2
McDermott JM ,Wirima JJ ,Steketee RW ,Breman JG ,Heymann DL . The effect of placental malaria infection on perinatal mortality in rural Malawi. Am J Trop Med Hyg 1996;55:Suppl:61-65
Web of Science | Medline3
Redd SC ,Wirima JJ ,Steketee RW ,Breman JG ,Heymann DL . Transplacental transmission of Plasmodium falciparum in rural Malawi. Am J Trop Med Hyg 1996;55:Suppl:57-60
Web of Science | Medline4
Steketee RW ,Wirima JJ ,Slutsker L ,Heymann DL ,Breman JG . The problem of malaria and malaria control in pregnancy in sub-Saharan Africa. Am J Trop Med Hyg 1996;55:Suppl:2-7
Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
C. J. Uneke. (2007) Congenital Plasmodium falciparum malaria in sub-Saharan Africa: a rarity or frequent occurrence?. Parasitology Research 101:4, 835-842
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