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Plasmodium Ovale Malaria Acquired in Central Spain

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Plasmodium Ovale Malaria Acquired in Central Spain DISPATCHES The Study Plasmodium ovale In March 2001, a 75-year-old woman was admitted to the Hospital Príncipe de Asturias in Madrid with a history of inter- Malaria Acquired in mittent fever for 1 week and no obvious infection. Intravenous treatment with ciprofloxacin was prescribed to treat provision- Central Spain ally diagnosed pyelonephritis. While in hospital, the patient Juan Cuadros,* Maria José Calvente,† had two episodes of high fever (39°C–40°C) separated by 48- Agustin Benito,‡ Juan Arévalo,* hour intervals with hypoxemia and deterioration of her general Maria Angeles Calero,* Javier Segura,† condition. On day 7 of fever, the hematologist advised the phy- and Jose Miguel Rubio‡ sician of the presence of rings inside the patient’s erythrocytes (parasitemia rate <1 %). A rapid antigen detection test (HRP2 We describe a case of locally acquired Plasmodium ovale detection; ICT Diagnostics, Amrad Corporation, Victor, Aus- malaria in Spain. The patient was a Spanish woman who had tralia) was done; the test returned negative results for Plasmo- never traveled out of Spain and had no other risk factors for dium falciparum and P. vivax. The sample was later identified malaria. Because patients with malaria may never have visited as P. ovale through microscopy and molecular studies at a ref- endemic areas, occasional transmission of malaria to Euro- erence malaria laboratory. Initial treatment with chloroquine pean hosts is a diagnostic and clinical challenge. followed by primaquine eliminated the infection successfully, and the patient recovered fully without complications. P. ovale was confirmed by semi-nested multiplex poly- n the first decades of the 20th century, malaria was a highly merase chain reaction (PCR) (8). DNA isolation was carried I endemic disease in Spain. After the civil war (1936–1939), out with Chelex (9) and the total DNA with the QIAamp DNA a large epidemic occurred; more than 293,000 cases and 1,278 Blood Mini Kit (QIAGEN GmbH, Hilden, Germany); the deaths were reported (1). As a result, public health officials in sample was amplified, and a 499-bp fragment compatible with Spain established strict control measures, and the disease was P. ovale was determined. PCR was repeated by using primers officially declared eradicated in 1964 (1). Malaria in Spain has at two different temperatures, and the presence of P. ovale been historically transmitted by Anopheles atroparvus and An. fragments was confirmed. The P. ovale fragments, initially labranchiae. However, in recent entomologic surveys con- embedded in the agarose gel, were then extracted with the help ducted in areas that were previously malarious, only An. atro- of the column for DNA purification. The rDNA was also parvus has been found in high densities similar to those amplified by using four specific primers (two forward and two observed during the years malaria was endemic (2,3). reverse) at two different temperatures to obtain a large quantity Since the eradication of malaria in Europe, locally of DNA for posterior sequencing. The product of amplification acquired malaria on the continent has usually been classified was sequenced in the ABISPRISM 377 XL DNA automatic as “airport” or “odyssean” malaria (transmitted by infected sequencer (PE Applied Biosystems, Foster City, CA). After- mosquitoes transported by airplanes, ships, containers, lug- wards, sequences were sent to the GenBank database; in all the gage, buses, and the like) (4,5), and cases of malaria reported cases, 100% homology for the small subunit of the P. ovale in Europe without identifiable risk factors have been classified rRNA gene was confirmed. as “cryptic” malaria (6). These cryptic cases may have occurred through local mosquito-borne transmission. In 1997, Epidemiologic Study a case of malaria was diagnosed in a patient from southern The patient had never traveled outside of Spain nor had Italy and identified as probable malaria transmitted by an any previous contact with people who had lived in or visited a autochthonous mosquito that fed on a gametogenic host; infor- country with endemic malaria. She had not received any pack- mation on this case was shared with public health officials in ages from malaria-endemic areas. Because of obesity and Europe to reduce the risk of reintroducing malaria into the instability from normotensive hydrocephalus, she had been Mediterranean basin (7). confined to her home since January 2000, except for two visits Because of its close proximity to Africa, Spain is one of to the hospital. She resides in an urban area close to two rivers the European countries most susceptible to the traffic of sub- (<1 km distance) and two international airports (Torrejón de Saharan migrant workers and the risk for transmission by mos- Ardoz [4 km distance] and Barajas [18 km distance]). The city quitoes migrating from other countries or indigenous in which the patient lives (Alcalá de Henares) is very close to anophelines infected by gametogenic hosts has increased sub- the Spanish capital, Madrid (30 km), an area with a meso- stantially. We describe a case of malaria in a European woman Mediterranean climate characterized by 400–500 mm of who had never traveled out of Spain and had no other risk fac- annual rainfall and average temperatures of 6°C in winter and tors for malaria. 22°C–24°C in summer. The city’s geographic conditions are semiarid with 3–4 months of dry seasons. Alcalá has 180,060 *Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain; †Consejería de Sanidad, Comunidad de Madrid, Madrid, Spain; and inhabitants, including 12,711 (7%) foreign residents; 1,121 ‡Instituto de Salud Carlos III, Madrid, Spain (0.6%) of the residents are Africans from malaria-endemic 1506 Emerging Infectious Diseases • Vol. 8, No. 12, December 2002 DISPATCHES countries located mostly in the western and central regions of considered in patients with a fever of unknown origin, even if Africa. they have never traveled to malaria-endemic areas. Increased We investigated the patient’s medical history for other risk attention should be given to persons who work or live close to factors for malaria. The patient’s uterus, ovaries, gall bladder, international airports or in areas with high population of new and appendix were removed >30 years ago, and she had never foreign residents from malarious areas. Hospital laboratories received any blood transfusions or blood derivates. Other risk should be ready to detect malaria parasitemia on a 24-hour factors such as needle-sharing, malariotherapy, or organ trans- basis (thick films or antigen detection if microscopy expert is plants were discarded. The possibility of iatrogenic transmis- unavailable) on a physician’s request. Likewise, PCR tech- sions during previous hospital admissions (the last visit was 3 niques should be used to detect retrospectively low para- weeks before onset of symptoms) was also investigated and sitemias and confirm the species diagnosis. We suggest that ruled out. epidemiologic and clinical attention should be given to travel- In the city in which the patient resides, the incidence of ers and newly arrived foreign residents from malaria-endemic malaria in 1999 and 2000 was 1.2 and 3.7 cases per 100,000 countries to prevent secondary cases (14). Simple, easy access inhabitants, respectively, but no cases were produced by P. to health care for recently arrived migrant workers should be ovale. In contrast, in the region surrounding Madrid, which implemented to assess risk factors and screen for malaria if includes two international airports, the incidence of imported necessary. malaria in 1999 and 2000 was, 2.7 and 3.4 cases per 100,000 inhabitants, respectively, (139 and 171 cases in total); P. ovale Acknowledgments was the species implicated in 2.1% and 5.3% of these regional We thank Tomas Jelinek and Gaby Peyerl for their expert techni- cases, respectively. Health care in Spain is free for foreign res- cal assistance and all the staff members at the laboratories of Hospital idents, but they must be inscribed in the local census bureau, Principe de Asturias and the Laboratorio de Referencia de Malaria of and many illegal foreign migrant or temporary workers are ISCIII for processing the specimens. We also thank Jerry Keller for likely not covered by any health insurance. editing the manuscript. Dr. Cuadros is a clinical microbiologist at the Servicio de Micro- Conclusions biologia in the Hospital Príncipe de Asturias of Alcalá de Henares, This case is the first locally acquired P. ovale infection Madrid, Spain. His main areas of interest include imported infectious connected with Europe. The infection may have been transmit- diseases and clinical parasitology. ted by an odyssean vector. The patient lives 4 and 18 km away from international airports, within the radius of other previ- References ously reported airport malaria cases (4,10). The parasite may 1. Blazquez J. [Susceptibility to malaria in Spain]. Rev Sanid Hig Publica also have been transmitted by a local mosquito (introduced (Madr) 1982;56;683–91. malaria) (5). In Spain, a possible vector for local infection is 2. Blazquez J. [Entomologic investigation on anophelism in the Ebro River An. atroparvus, since this species has shown receptivity to P. delta]. Rev Sanid Hig Publica (Madr) 1974;48:363–77. vivax (11) and possibly could be receptive to P. ovale as well. 3. Eritja R, Aranda C, Padros J, Goula M. Revised checklist of the Spanish Surprisingly, the illness began when cold temperatures pre- mosquitoes. Acta Virologica Portuguesa 1998;5:25. 4. Isaacson M. Airport malaria: a review. Bull World Health Organ vailed. Thus, the disease could have been a relapse from 1989;67:737–43. hepatic hypnozoite or a primoinfection produced by the bite of 5. Isaacson M, Frean JA. African malaria vectors in European aircraft. Lan- an inhouse hibernating infected Anopheles spp. female (12). cet 2001;357:235.
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