Airport Malaria: Report of a Case and a Brief Review of the Literature

CASE REPORT

Airport malaria: report of a case and a brief review of the literature

H.D. Thang1, R.M. Elsas2, J. Veenstra1

1Department of Internal Medicine, St. Lucas Andreas Hospital, Jan Tooropstraat 164, 1061 AE Amsterdam, the Netherlands, tel.: +31 (0)20-510 87 71, fax: +31 (0)20-683 87 71, e-mail: [email protected], 2general practitioner, Confusiusplein 10, 1064 LG Amsterdam, the Netherlands, tel.: +31 (0)20-63 00 83

ABSTRACT

We report a case of Plasmodium vivax malaria in a patient On physical examination a moderately ill woman was seen. who had not visited an endemic area. The ways in which Her body temperature was 40.1°C, the blood pressure malaria can be transmitted in non-endemic areas are 120/80 mmHg with a pulse rate of 100 beats/minute. discussed. By the elimination of other possibilities, the Further examination showed no abnormalities. Laboratory diagnosis of airport malaria was made. Airport malaria is investigations revealed an ESR of 28 mm/hour, leucopenia a rare and often initially overlooked diagnosis. Since 1969, (2.9 x 109/l) with a lymphocytopenia (0.55 x 109/l), some 89 cases of airport malaria have been reported. thrombocytopenia (55 x 109/l) and slightly elevated liver enzymes (ASAT 73 U/l, ALAT 110 U/l, GGT 100 U/l, LDH 589 U/l). Blood cultures remained negative. Serological tests (MEIA, Abbott) showed elevated IgM INTRODUCTION and IgG antibodies to cytomegalovirus (CMV). The CMV- IgM index was 2.5 (the cut-off point of positive is 0.5). Malaria occurs throughout most of the tropical regions of The CMV-IgG titre was 142 U/ml (a titre >15 U/ml is the world. In febrile patients in non-endemic areas, an considered to be positive). Therefore, a recently acquired accurate travel history may reveal the essential clue to the CMV infection was suspected. Within five days her body diagnosis of malaria. Without a history of travelling to temperature returned to normal and the laboratory areas where this protozoan disease is transmitted, the investigations normalised. diagnosis of malaria is highly unlikely, but not excluded. However, after two weeks the fever returned with a spiking A case of Plasmodium vivax malaria in a patient who had pattern in a 48-hour cycle (figure 1). She now complained of not visited an endemic area is reported. shivering, night sweats and muscular pains. The laboratory investigations revealed anaemia (5.9 mmol/l). The white blood cell count, platelet count and liver enzymes were in CASE REPORT the normal range. A thorough history was taken. Our patient had never travelled outside Europe and therefore In August 2001, a 43-year-old woman was seen in the malaria was considered as highly unlikely. However, outpatient clinic for internal medicine because of persisting because of the periodic nature of the fever her general fever without other symptoms. The fever started five days practitioner had ordered a blood smear for malaria. To our after the return of a trip by car to Sweden. She lived and surprise this smear and a repeated smear were positive worked in the western part of Amsterdam and had never for P. vivax with a parasitaemia of <1%. visited a country outside Europe. The patient had been Since our patient lived in the surroundings of the treated with amoxycillin-clavulanic acid without any international airport Schiphol, we assumed that she was improvement. suffering from airport malaria.

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Temperature (celsius) 36

34 1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 Day

Figure 1 Pattern of fever in a patient with plasmodium vivax malaria

The patient was treated with chloroquine base (600 mg In airport malaria, the mosquito can be dispersed as far as first day, 600 mg second day, 300 mg third day), followed seven kilometres under favourable wind conditions or may by primaquine (15 mg daily) for 14 days. She made a full have been transported in baggage or in a motor vehicle after recovery and the laboratory abnormalities normalised. disembarking from the aeroplane for tens of kilometres. At such distances from the airport there may be little suspicion that a patient’s illness is caused by malaria.11,12 DISCUSSION Two cases of presumed airport malaria have been reported in the Netherlands.13 Similar to the above-mentioned We report a case of P. vivax malaria in the Netherlands in patient, these cases also occurred in the surroundings of a patient who had never travelled to malaria endemic Schiphol during the month of August. During the summer areas. We have no doubts about the precision of her travel season the temperature may facilitate the survival of the history. Indigenous malaria caused by P. vivax has not imported vector. been seen in the Netherlands since 19581 and in Sweden Between 1969 and 1999, 89 cases of airport malaria since 1910.2 were reported, most of them in France, Belgium and the In patients without a history of travelling to malaria United Kingdom.14 The occurrence of a relatively large endemic areas some rare cases of malaria have been number of cases of airport malaria in these countries reported as transfusion malaria, nosocomial malaria and reflects the large number of flights arriving from endemic airport or port malaria. Transfusion malaria can occur malaria countries. The majority of cases of airport malaria through transmission of Plasmodium-infected blood were caused by Plasmodium falciparum.15 products.3 Nosocomial malaria has been reported as malaria Long delay in achieving the correct diagnosis of airport transmitted by needlestick injuries,4 contact of blood to malaria may account for a relatively high mortality of 6% an open wound or through injection fluid accidentally in France and Belgium.14 contaminated with Plasmodium due to failing hospital Our patient had never received any blood products and had hygiene.5-8 Airport malaria, and even more rarely port not been injured by needlesticks. She lives and recreates malaria, is acquired through the bite of a tropical near the international airport Schiphol. By elimination of anopheline mosquito in people whose geographical history other possibilities, we concluded that our patient suffered excludes exposure to this vector in its natural habitat.9,10 from airport malaria. In retrospect, the first episode of

Thang, et al. Airport malaria: report of a case and a brief review of the literature

DECEMBER 2002, VOL. 60, NO. 11 442 fever in our patient could have been the first symptom of 6. Chen KT, Chen CJ, Chang PY, Morse DL. A nosocomial outbreak of malaria malaria with a false-positive reaction of CMV-IgM anti- associated with contaminated catheters and contrast medium of a computed bodies. tomographic scanner. Infect Control Hosp Epidemiol 1999;20:22-5. Although the risk of airport malaria seems to be very low, 7. Al-Saigul AM, Fontaine RE, Haddad Q. Nosocomial malaria from medical practitioners should remain aware of the rare contamination of a multidose heparin container with blood. Infect possibility of malaria in patients presenting with fever, Control Hosp Epidemiol 2000;21:329-30. who have travelled by plane, stayed at international airports 8. Piro S, Sammud M, Badi S, Al Ssabi L. Hospital-acquired malaria or who live near an international airport or port. transmitted by contaminated gloves. J Hosp Infect 2001;47:156-8. 9. Issaäcson M. Airport malaria: a review. Bull World Health Organ 1989;67:737-43. REFERENCES 10. Peleman R, Benoit D, Goossens L, et al. Indigenous malaria in a suburb of Ghent, Belgium. J Travel Med 2000;7:48-9. 1. Meuleman EA, Mellink JJ, Koelewijn M. Medische parasitologie en 11. Giacomini T, Mouchet J, Mathieu P, Petithory JC. Etude de six cas de entomologie. 2nd ed. Amsterdam: VU Uitgeverij, 1989:69-83. paludisme contractés près de Roissy-Charles-de Gaulle en 1994. Mesures de 2. Jaenson TG. Malaria in Sweden-entomological aspects. Lakartidningen prévention nécessaires dans les aéroports. Bull Acad Natl Med 1995;179:II:335-53. 1983;8;80(23):2418-21. 12. Praetorius F, Altrock G, Blees N, Schuh N, Faulde M. Importierte anopheles: 3. Mungai M, Tegtmeier G, Chamberland M, Parise M. Transfusion-transmitted im gepäck oder aus dem Flugzeug? Dtsch Med Wochenschr 1999;124:998-1002. malaria in the United States from 1963 through 1999. N Engl J Med 13. Delemarre BJM, Kaay HJ van der. Malaria tropica op natuurlijke wijze 2001;344:1973-8. verkregen in Nederland. Ned Tijdschr Geneeskd 1979;123:46;1981-2. 4. Agtmael MA van. A most unfortunate needlestick injury. BMJ 1997;314:337. 14. Gratz N, Steffen R, Cocksedge W. Why aircraft disinfection? Bull World 5. Abulrahi HA, Bohlega EA, Fontaine RE, Al-Seghayer SM, Al-Ruwais AA. Health Organ 2000;78(8):995-1004. Plasmodium falciparum malaria transmitted in hospital through heparin 15. Giacomini T. Paludisme des aéroports et de leurs alentours. Rev Prat locks. Lancet 1997;349:23-5. 1998;48:264-7.

Thang, et al. Airport malaria: report of a case and a brief review of the literature

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