Correspondence

Malaria Acquired 13 Times in Two Years in Germany

N Engl J Med 1997; 337:1636-1637November 27, 1997

Article

To the Editor:

A 45-year-old German hospital-laboratory technician spent her holiday in Tanzania in March 1994 under malaria prophylaxis with chloroquine and proguanil (chloroguanide). In October 1994 she had fever and headache. A thick blood smear revealed Plasmodium falciparum. She was treated immediately with halofantrine, which led to the relief of symptoms and clearance of the parasites. In January 1995 falciparum malaria developed again, and the patient was treated with mefloquine. She had her next bout of falciparum malaria in March 1995 and received oral quinine and doxycycline therapy. In August 1995, during the fourth attack, she received quinine and doxycycline intravenously under supervision. A fifth episode, in September 1995, was treated with oral artesunate. In October 1995 artesunate was combined with sulfadoxine and pyrimethamine when she had her sixth attack. For attack number seven, in November 1995, quinine therapy was combined with clindamycin. In December 1995 artesunate was combined with chloroquine for her eighth episode of falciparum malaria. Her physicians, who by then were suspicious, undertook studies of the parasite. P. falciparum parasites from attacks number 9 (February 1996, treated with chloroquine and proguanil), number 10 (April 1996, treated with chloroquine and clindamycin), number 11 (June 1996, treated with atovaquone and proguanil), number 12 (August 1996, treated with quinine), and number 13 (December 1996, treated with chloroquine) were investigated for in vitro sensitivity to chloroquine, quinine, and mefloquine1 and for the genotypic pattern of their merozoite surface antigen 1 (MSA-1) polymorphisms.2,3

Parasites from attacks 10 and 12 showed a high susceptibility to quinine and mefloquine and resistance to chloroquine. Furthermore, the different lengths of polymerase-chain-reaction fragments from the MSA-1 gene clearly showed different parasite genotypes in attacks 9 through 13 (Figure 1Figure 1DNA Fragments Generated from the Patient's Blood.).

In this case, no other underlying disease was found, antimalarial treatments that are usually effective were not radically curative, the parasites were highly sensitive to quinine and mefloquine (both had been administered in earlier attacks), and clear-cut differences in parasite genotypes from one attack to the other were demonstrated. These circumstances led the responsible physicians to interrogate the patient. A rather prompt confession uncovered the mystery of the case. The patient, having had access to infected blood from other patients, was infecting herself by repeated intravenous inoculations of amounts of as much as 1 ml of fresh parasitized blood from various donors. The patient is now receiving psychiatric treatment.

Jürgen F.J. Kun, Ph.D.
Peter G. Kremsner, M.D.
University of Tübingen, D-72074 Tübingen, Germany

Harald Kretschmer, M.D.
Paul-Lechler-Krankenhaus, D-72076 Tübingen, Germany

3 References

1. 1

   Wernsdorfer WH, Wernsdorfer MG. The evaluation of in vitro tests for the assessment of drug response in Plasmodium falciparum. Mitt Österreichischen Ges Tropenmed Parasitol 1996;17:221-8.
   

2. 2

   McBride JS, Newbold CI, Anand R. Polymorphism of a high molecular weight schizont antigen of the human malaria parasite Plasmodium falciparum. J Exp Med 1985;161:160-180
   CrossRef | Web of Science | Medline

3. 3

   Kimura E, Mattei D, di Santi SM, Scherf A. Genetic diversity in the major merozoite surface antigen of Plasmodium falciparum: high prevalence of a third polymorphic form detected in strains derived from malaria patients. Gene 1990;91:57-62
   CrossRef | Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   Christopher J. Gill, Davidson H. Hamer. (2002) “Doc, There's a Worm in My Stool”: Munchausen Parasitosis in a Returning Traveler. Journal of Travel Medicine 9:6, 330-332
   CrossRef

2. 2

   Yves Poinsignon, Catherine Arfi, Claudine Sarfati, Dominique Farge-Bancel, Christian P. Raccurt. (1999) Case report: French West Indies - a tourist destination at risk for Plasmodium falciparum transmission?. Tropical Medicine and International Health 4:4, 255-256
   CrossRef