Correspondence

Reactivation of Plasmodium malariae Infection in a Trinidadian Man after Neurosurgery

N Engl J Med 2000; 342:1924June 22, 2000

Article

To the Editor:

Malaria often presents as an acute febrile illness with fever, headache, rigors, anemia, and splenomegaly. The only malaria parasite associated with cerebral complications, Plasmodium falciparum usually blocks cerebral capillaries because of its endothelial adhesiveness.1 Infections with P. malariae can persist for decades and are associated with splenomegaly and the nephrotic syndrome2 but not with cerebral complications. We describe P. malariae infection that was reactivated after neurosurgery after decades of latency.

In September 1998, a 70-year-old Trinidadian man with a history of pulmonary tuberculosis presented with a right hemiparesis. A computed tomographic scan of the brain showed an abscess of the left parietal lobe, and neurosurgery was performed to remove the cerebral abscess. Antituberculosis therapy was instituted, but no blood transfusions were administered. Seven days later, rigors, headache, and fever (a temperature of up to 39°C) developed, and these symptoms recurred in a quartan pattern for four cycles. The patient denied ever traveling to a country where malaria was endemic or having malaria as a child — that is, before 1965, when malaria was eradicated in Trinidad.3 His hemoglobin level was 8 g per deciliter, and the platelet count was 181,000 per cubic millimeter. The results of hemoglobin electrophoresis were normal, as were the levels of glucose-6-phosphate dehydrogenase. Renal function and liver function were normal, and splenomegaly was not detected. Light-microscopical analysis of thick blood smears revealed 1 to 10 P. malariae parasites per 100 fields (100×, oil-immersion lens).

The patient was treated with the standard regimen of chloroquine phosphate and primaquine phosphate for 14 days, and parasitemia resolved by day 2. One year later, no recrudescences had occurred.

Infections with P. malariae may be asymptomatic and can be reactivated decades after the initial infection. Vinetz et al.4 reported a case of P. malariae infection in an asymptomatic 74-year-old Greek woman some 40 years after malaria had been eradicated in Greece. Because malaria was eradicated in Trinidad and Tobago in 1965,3 our patient could have had this infection for more than 30 years and perhaps, given his clinical history, about 65 years.

This case has a number of interesting features. The symptoms of malaria occurred after neurosurgery to remove a parietal-lobe abscess. The levels of parasitemia were high enough to allow detection of the protozoa by light microscopy. Antibiotics (amoxicillin–clavulanate and streptomycin) were administered after surgery, and they had some antimalarial effects but not enough to suppress the episodes of quartan fever.

The epidemiologic significance of asymptomatic cases of P. malariae infection has been well documented during outbreaks in Trinidad and Tobago and Grenada.5 Most of the symptomatic cases were detected by microscopical analysis, whereas the asymptomatic cases were diagnosed with the use of immunofluorescence antibody assays.4,5 Subclinical infections in humans may serve as the source of the protozoa in mosquitoes. Consequently, it is recommended that a sensitive technique that is based on the polymerase chain reaction be used to screen persons for persistent malaria infections, especially those who live in regions where the disease was once common but has since been eradicated.

Dave D. Chadee, Ph.D., D.Sc.
Clive C. Tilluckdharry, M.B., B.S., M.P.H.
Insect Vector Control Division, St. Joseph, Trinidad, West Indies

Paramanand Maharaj, M.B., B.S.
University of the West Indies, Mt. Hope, Trinidad, West Indies

C. Sinanan, M.B., B.Ch.
Caura Chest Hospital, Caura, Trinidad, West Indies

5 References

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   Krogstad DJ. Plasmodium species (malaria). In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas and Bennett's principles and practice of infectious diseases. 4th ed. Vol. 2. New York: Churchill Livingstone, 1995:2415-27.
   

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   Register of malaria eradication of Trinidad and Tobago. Washington, D.C.: Pan American Health Organization, 1965.
   

4. 4

   Vinetz JM, Li J, McCutchan TF, Kaslow DC. Plasmodium malariae infection in an asymptomatic 74-year-old Greek woman with splenomegaly. N Engl J Med 1998;338:367-371
   Full Text | Web of Science | Medline

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   Chadee DD, Beier JC, Doon R. Re-emergence of Plasmodium malariae in Trinidad, West Indies. Ann Trop Med Parasitol 1999;93:467-475
   CrossRef | Web of Science | Medline

Citing Articles (5)

Citing Articles

1. 1

   J. D. Maguire, J. K. Baird. (2010) The 'non-falciparum' malarias: the roles of epidemiology, parasite biology, clinical syndromes, complications and diagnostic rigour in guiding therapeutic strategies. Annals of Tropical Medicine and Parasitology 104:4, 283-301
   CrossRef

2. 2

   Tonya Jagneaux, Fred A Lopez, Charles V Sanders. 2007. Postoperative Fever of Unknown Origin. , 115-132.
   CrossRef

3. 3

   D. R. Snydman, M. Walker, J. G. Kublin, J. R. Zunt. (2006) Parasitic Central Nervous System Infections in Immunocompromised Hosts: Malaria, Microsporidiosis, Leishmaniasis, and African Trypanosomiasis. Clinical Infectious Diseases 42:1, 115-125
   CrossRef

4. 4

   Miro Morovic, Ivica Poljak, Bojan Miletic, Biserka Troselj-Vukic, Irene Seili-Bekafigo, Irena Milotic. (2003) Late Symptomatic Plasmodium malariae Relapse in the Territory of the Former Yugoslavia. Journal of Travel Medicine 10:5, 301-302
   CrossRef

5. 5

   (2000) Malaria in a Trinidadian Man. New England Journal of Medicine 343:14, 1046-1047
   Full Text

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