[A case of neonatal congenital malaria accompanied with severe thrombocytopenia]

This article reports the process of diagnosis and treatment of one case of neonatal congenital malaria accompanied with severe thrombocytopenia.

CONGENITAL MALARIA

Neonates with congenital malaria may present with non-specific signs and symptoms which may be mistaken for neonatal sepsis and inborn error of metabolism resulting in delay of diagnosis.and significant mortality and morbidity. Here we present a unique case of 25 days old premature female baby who was diagnosed to have mixed malarial infection. Despite standard treatment the patient was not responding well and was also diagnosed to have congenital adrenal hyperplasia.

[Congenital malaria in a hospital in Iquitos, Peru]

OBJECTIVES

To determine the frequency and clinical features of newborns with congenital malaria in the Hospital de Apoyo of Iquitos in the Peruvian Amazon.

MATERIALS AND METHODS

Descriptive, prospective and cross-sectional study. From January 2011 to December 2013, 14.017 newborns and their mothers were studied, of whom 52 carriers of gestational malaria were selected while their infants were hospitalized in the Neonatology Unit, and underwent clinical assessment and laboratory studies.

RESULTS

Gestational malaria frequency was 0.4% and a proportion of 9.6% of congenital malaria. Plasmodium vivax was found in 80% of cases of gestational malaria and in 60% of congenital malaria. A case of fetal death with positive thick blood smear for Plasmodium falciparum was observed. The clinical presentation in newborns was fever, hypoactivity, irritability and poor suction.

CONCLUSIONS

The presence of congenital malaria in infants born to mothers with gestational malaria is documented. The clinical picture resembled neonatal sepsis. Early diagnosis of congenital malaria and timely treatment present with good evolution.

Pregnancy-associated malaria and malaria in infants: an old problem with present consequences

Albeit pregnancy-associated malaria (PAM) poses a potential risk for over 125 million women each year, an accurate review assessing the impact on malaria in infants has yet to be conducted. In addition to an effect on low birth weight (LBW) and prematurity, PAM determines foetal exposure to Plasmodium falciparum in utero and is correlated to congenital malaria and early development of clinical episodes during infancy. This interaction plausibly results from an ongoing immune tolerance process to antigens in utero, however, a complete explanation of this immune process remains a question for further research, as does the precise role of protective maternal antibodies. Preventive interventions against PAM modify foetal exposure to P. falciparum in utero, and have thus an effect on perinatal malaria outcomes. Effective intermittent preventive treatment in pregnancy (IPTp) diminishes placental malaria (PM) and its subsequent malaria-associated morbidity. However, emerging resistance to sulphadoxine-pyrimethamine (SP) is currently hindering the efficacy of IPTp regimes and the efficacy of alternative strategies, such as intermittent screening and treatment (IST), has not been accurately evaluated in different transmission settings. Due to the increased risk of clinical malaria for offspring of malaria infected mothers, PAM preventive interventions should ideally start during the preconceptual period. Innovative research examining the effect of PAM on the neurocognitive development of the infant, as well as examining the potential influence of HLA-G polymorphisms on malaria symptoms, is urged to contribute to a better understanding of PAM and infant health.

Congenital malaria in China

Abstract

Background

Congenital malaria, in which infants are directly infected with malaria parasites from their mother prior to or during birth, is a potentially life-threatening condition that occurs at relatively low rates in malaria-endemic regions. It is recognized as a serious problem in Plasmodium falciparum–endemic sub-Saharan Africa, where recent data suggests that it is more common than previously believed. In such regions where malaria transmission is high, neonates may be protected from disease caused by congenital malaria through the transfer of maternal antibodies against the parasite. However, in low P. vivax–endemic regions, immunity to vivax malaria is low; thus, there is the likelihood that congenital vivax malaria poses a more significant threat to newborn health. Malaria had previously been a major parasitic disease in China, and congenital malaria case reports in Chinese offer valuable information for understanding the risks posed by congenital malaria to neonatal health. As most of the literature documenting congenital malaria cases in China are written in Chinese and therefore are not easily accessible to the global malaria research community, we have undertaken an extensive review of the Chinese literature on this subject.

Methods/Principal Findings

Here, we reviewed congenital malaria cases from three major searchable Chinese journal databases, concentrating on data from 1915 through 2011. Following extensive screening, a total of 104 cases of congenital malaria were identified. These cases were distributed mainly in the eastern, central, and southern regions of China, as well as in the low-lying region of southwest China. The dominant species was P. vivax (92.50%), reflecting the malaria parasite species distribution in China. The leading clinical presentation was fever, and other clinical presentations were anaemia, jaundice, paleness, diarrhoea, vomiting, and general weakness. With the exception of two cases, all patients were cured with antimalarial drugs such as chloroquine, quinine, artemether, and artesunate.

Conclusions

The symptoms of congenital malaria vary significantly between cases, so clear and early diagnosis is difficult. We suggest that active surveillance might be necessary for neonates born to mothers with a history of malaria.

Congenital malaria--a neglected problem

Congenital malaria is the least known manifestation of malaria and a much neglected area of research. Most of the existing information is limited to case reports in children born to non-immune women. Congenital malaria can be acquired by transmission of parasitised maternal erythrocytes across the placenta due to microdamage. Congenital malaria has been documented for many years but it was previously thought to be uncommon especially in indigenous populations. Many gaps in knowledge remain. There is a need of considering congenital malaria as differential diagnosis even in low endemic areas, especially in countries where there is social practice of moving the pregnant woman to her native place for childbirth, which may be endemic for malaria. Physicians should judge each case individually, considering such factors as reliability of follow-up and access to medical care and advice accordingly.

Congenital malaria in Thailand

Congenital malaria, although considered to be relatively rare, is not uncommon now, and prevalence rates vary between geographical regions. Fifteen cases of congenital malaria admitted from various parts of Thailand are reviewed. Most came from Thai border areas.

Congenital malaria in newborn twins

A 28-year-old woman (G2P1A), with 36 weeks gestation, reported to a health facility in Sunyani on 22(nd) February 2009 with history of labour pains, without fever. She was reported to have taken sulphadoxine-pyrimethamine for malaria prophylaxis during the pregnancy but did not use insecticide-treated net. She delivered twins on the same day. The mother and the twins developed fever on the same day. A laboratory investigation on the three of them was positive for malaria parasites. The three were successfully treated with quinine. Congenital malaria is real and it is therefore recommended that babies born to mothers with malaria should be screened for congenital malaria.

Malaria surveillance--United States, 2009

PROBLEM/CONDITION

Malaria in humans is caused by intraerythrocytic protozoa of the genus Plasmodium. These parasites are transmitted by the bite of an infective female Anopheles mosquito. The majority of malaria infections in the United States occur among persons who have traveled to areas with ongoing malaria transmission. In the United States, cases can occur through exposure to infected blood products, congenital transmission, or local mosquitoborne transmission. Malaria surveillance is conducted to identify episodes of local transmission and to guide prevention recommendations for travelers.

PERIOD COVERED

This report summarizes cases in persons with onset of illness in 2009 and summarizes trends during previous years.

DESCRIPTION OF SYSTEM

Malaria cases diagnosed by blood film, polymerase chain reaction or rapid diagnostic tests are mandated to be reported to local and state health departments by health-care providers or laboratory staff. Case investigations are conducted by local and state health departments, and reports are transmitted to CDC through the National Malaria Surveillance System (NMSS), National Notifiable Diseases Surveillance System (NNDSS), or direct CDC consults. Data from these reporting systems serve as the basis for this report.

RESULTS

CDC received reports of 1,484 cases of malaria, including two transfusion-related cases, three possible congenital cases, one transplant case and four fatal cases, with an onset of symptoms in 2009 among persons in the United States. This number represents an increase of 14% from the 1,298 cases reported for 2008. Plasmodium falciparum, P. vivax, P. malariae, and P. ovale were identified in 46%, 11%, 2%, and 2% of cases, respectively. Thirteen patients were infected by two or more species. The infecting species was unreported or undetermined in 38% of cases. Among the 1,484 cases 1,478 were classified as imported. Among the 103 U.S. civilians for whom information on chemoprophylaxis use and travel area was known, only 34 (33%) reported that they had followed and adhered to a chemoprophylactic drug regimen recommended by CDC for the area to which they had traveled. Nineteen cases were reported in pregnant women, among whom none adhered to chemoprophylaxis. Almost 22% of the cases among pregnant women were treated with an inappropriate treatment drug regimen, of which 39% were among cases with either a P. vivax or P. ovale infection where primaquine was not taken. Among all the reasons for travel, travelers visiting friends and relatives (VFR) and missionaries were the groups with the lowest proportion of chemoprophylexis use.

INTERPRETATION

A notable increase in the number of malaria cases was reported from 2008 to 2009; however, the number of cases in 2009 is consistent with the average number of cases reported during the preceding 4 years. In the majority of reported cases, U.S. civilians who acquired infection abroad had not adhered to a chemoprophylaxis regimen that was appropriate for the country in which they acquired malaria. Furthermore, treatment of malaria, while appropriate for the majority of cases, was insufficient for a large number of P. vivax and P. ovale infections, putting patients at risk for relapsing malaria.

PUBLIC HEALTH ACTIONS

Decreasing the number of malaria cases in subsequent years will require conveying the importance of adhering to appropriate preventive measures for malaria specifically targeting travelers visiting friends and relatives, missionary, and pregnant populations. Clinicians require education on the need to encourage use of malaria prophylaxis and need further information on the appropriate diagnostic and treatment guidelines for malaria. Malaria prevention recommendations are available online (http://www.cdc.gov/malaria/travelers/ or http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/malaria.aspx#990). Malaria infections can be fatal if not diagnosed and treated promptly with antimalarial medications appropriate for the individual patient's age and medical history, the likely site of malaria acquisition, and previous use of antimalarial chemoprophylaxis. Clinicians should consult the CDC Guidelines for Treatment and contact the CDC's Malaria Hotline for case management advisement when needed. Malaria treatment recommendations can be obtained online (http://www.cdc.gov/malaria/diagnosis_treatment) or by calling the Malaria Hotline (770-488-7788).

Congenital malaria: a case report

Malaria is an important vector-borne infectious disease, caused by plasmodium parasite. Congenital malaria, however, is rare and may be acquired either during pregnancy, at the time of delivery or after birth. A case of symptomatic congenital malaria caused by Plasmodium vivax and characterised by fever, irritability, pallor and jaundice, is presented in a 4-week-old infant.

Risk factors associated with congenital malaria in Enugu, South Eastern Nigeria

There is paucity of data on the risk factors associated with congenital malaria in Nigeria. This study assessed the risk factors for congenital malaria in a population of neonates delivered at the University of Nigeria Teaching Hospital, Enugu, South Eastern Nigeria. It was a prospective cross-sectional study of neonates who were delivered in the institution from 2 April 2003 to 15 April 2004 as well as their mothers. Thick and thin blood films were made from maternal, baby and cord blood as well as the placenta for each mother/baby pair to determine malaria parasite density counts and for species identification. The maternal samples were obtained as soon as labour was confirmed while the cord and baby's blood as well as placental smears were taken within 1 h of delivery. Data analysis was by means of descriptive and inferential statistics as well as univariate and multivariate logistic regression at the 95% confidence level using the statistical software SPSS for Windows Version 10. A total of 658 mother/baby pairs were recruited into the study within the 13-month period. Out of this number, 625 mother/baby pairs completed the study and their data were subsequently analysed. A total of 356 (56.96%) mothers and 203 (32.48%) babies were smear positive for Plasmodium falciparum. On univariate logistic regression with presence or absence of the congenital malaria as the dependent variable, six out of the 13 putative risk factors tested were statistically significant. These were low compared with higher socioeconomic classes (OR = 1.41, 95% CI = 1.18 - 1.69, p = 0.00); low compared with normal birth weight (OR = 2.14, 95% CI = 1.39 - 3.30, p = 0.001); positive placental malaria parasitaemia (OR = 6.29, 95% CI, 4.73 - 8.37, p = 0.000), positive maternal blood malaria parasitaemia (OR = 5.04, 95% CI = 3.74 - 6.78, p = 0.000), positive cord blood malaria parasitaemia (OR = 26.87, 95% = 15.79 - 45.74, p = 0.000) and parity of 0 - 1 compared with other parities (OR = 1.31, 95% CI = 1.11 - 1.55, p = 0.002). On multivariate logistic regression, three of the six factors that were significant on univariate logistic regression remained significant. These were: positive placental malaria parasitaemia (OR = 2.55, 95% CI = 1.45 - 4.47, p = 0.001); positive cord malaria parasitaemia (OR = 18.90, 95% CI = 10.68 - 33.46, p = 0.000 and parity of 0 - 1 compared with other parities (OR = 1.66, 95% CI = 1.09 - 2.52, p = 0.02). It was concluded that the risk factors for congenital malaria identified in this study emphasise the need for effective preventive and curative treatment of malaria not only during pregnancy but also during delivery in malaria endemic areas. Additionally, congenital malaria should now rank high among the list of differential diagnosis of fever in the newborn in such endemic areas.

Congenital malaria in neonates: two case reports and review of the literature

Congenital malaria is uncommon in nonendemic countries. We describe two cases involving neonates hospitalized with fever, anaemia and thrombocytopaenia. Thick and thin blood smears were positive for Plasmodium vivax (P. vivax) and P. ovale, respectively. These two cases were discussed regarding the literature and potential implications of HIV coinfection in the mother.

CONCLUSION

Consistent data in the literature suggest that peripheral blood films should be performed in HIV-positive women who travelled to an endemic area or with a history of malaria prior to gestation. With today's travelling patterns, congenital malaria should be considered as an important differential diagnosis of neonatal sepsis.

Malaria surveillance - United States, 2005

PROBLEM/CONDITION

Malaria in humans is caused by any of four species of intraerythrocytic protozoa of the genus Plasmodium (i.e., P. falciparum, P. vivax, P. ovale, or P. malariae). These parasites are transmitted by the bite of an infective female Anopheles sp. mosquito. The majority of malaria infections in the United States occur among persons who have traveled to or from areas with ongoing malaria transmission. In the United States, cases can occur through exposure to infected blood products, congenital transmission, or local mosquitoborne transmission. Malaria surveillance is conducted to identify episodes of local transmission and to guide prevention recommendations for travelers.

PERIOD COVERED

This report summarizes cases in persons with onset of illness in 2005 and summarizes trends during previous years.

DESCRIPTION OF SYSTEM

Malaria cases confirmed by blood film or polymerase chain reaction (PCR) are mandated to be reported to local and state health departments by health-care providers or laboratory staff. Case investigations are conducted by local and state health departments, and reports are transmitted to CDC through the National Malaria Surveillance System (NMSS). Data from NMSS serve as the basis for this report.

RESULTS

CDC received reports of 1,528 cases of malaria, including seven fatal cases, with an onset of symptoms in 2005 among persons in the United States or one of its territories. This number represents an increase of 15.4% from the 1,324 cases reported for 2004. P. falciparum, P. vivax, P. malariae, and P. ovale were identified in 48.6%, 22.1%, 3.5%, and 2.5% of cases, respectively. Twelve patients (0.8% of total) were infected by two or more species. The infecting species was unreported or undetermined in 22.6% of cases. Compared with 2004, the largest increases in cases came from the Americas (23.1%; n = 213) and Asia and the Middle East (18.6%; n = 204). On the basis of estimated volume of travel, the highest estimated case rates of malaria among travelers occurred among those returning from West Africa. Of 870 U.S. civilians who acquired malaria abroad, only 160 (18.4%) reported that they had followed a chemoprophylactic drug regimen recommended by CDC for the area to which they had traveled. Two patients became infected in the United States, both attributed to congenital transmission; both were infected with P. vivax. Seven deaths were attributed to malaria, all caused by infection with P. falciparum.

INTERPRETATION

The 15.4% increase in malaria cases in 2005, compared with 2004, resulted primarily from increases in the number of cases reported from Asia and the Middle East and from the Americas. This increase might in part reflect more complete reporting and in part increased travel to malarious areas. No change was noted in proportions of cases from other areas of the world, or in species responsible for the infection. In the majority of reported cases, U.S. civilians who acquired infection abroad had not adhered to a chemoprophylaxis regimen that was appropriate for the country in which they acquired malaria. U.S. civilians who traveled to West Africa had the highest estimated relative case rate.

PUBLIC HEALTH ACTIONS

Additional investigations were conducted for the seven fatal cases and two infections acquired in the United States. Persons traveling to a malarious area should take one of the recommended chemoprophylaxis regimens appropriate for the region of travel and use personal protection measures to prevent mosquito bites. Any person who has been to a malarious area and who subsequently has a fever or influenza-like symptoms should seek medical care immediately and report their travel history to the clinician; investigation should include at least one blood-film test for malaria. Malaria infections can be fatal if not diagnosed and treated promptly. Recommendations concerning malaria prevention can be obtained from CDC at http://www.cdc.gov/travel or by calling the Malaria Hotline (telephone 770-488-7788). Recommendations for malaria treatment can be obtained at http://www.cdc.gov/malaria/diagnosis_treatment/treatment.htm or by calling the Malaria Hotline.

Congenital malaria: the least known consequence of malaria in pregnancy

Congenital malaria is the least known manifestation of malaria and a very neglected area of research. Most of the existing information is limited to case reports in children born to non-immune women. With the use of molecular techniques, congenital infection is being increasingly detected among infants born to semi-immune women in endemic countries. However, many gaps in knowledge remain. The mechanisms and timing of infection are unclear. Furthermore, there is a lack of information on the impact of congenital malaria infection on the subsequent risk of malaria and general morbidity in the infant. There is also a lack of consensus on the clinical guidelines for its management. More research is needed in order to establish adequate preventive and management recommendations to avoid this consequence of malaria in pregnancy.

Treatment of malaria in the United States: a systematic review

CONTEXT

Many US clinicians and laboratory personnel are unfamiliar with the diagnosis and treatment of malaria.

OBJECTIVES

To examine the evidence base for management of uncomplicated and severe malaria and to provide clinicians with practical recommendations for the diagnosis and treatment of malaria in the United States.

EVIDENCE ACQUISITION

Systematic MEDLINE search from 1966 to 2006 using the search term malaria (with the subheadings congenital, diagnosis, drug therapy, epidemiology, and therapy). Additional references were obtained from searching the bibliographies of pertinent articles and by reviewing articles suggested by experts in the treatment of malaria in North America.

EVIDENCE SYNTHESIS

Important measures to reduce morbidity and mortality from malaria in the United States include the following: obtaining a travel history, considering malaria in the differential diagnosis of fever based on the travel history, and prompt and accurate diagnosis and treatment. Chloroquine remains the treatment of choice for Plasmodium falciparum acquired in areas without chloroquine-resistant strains. In areas with chloroquine resistance, a combination of atovaquone and proguanil or quinine plus tetracycline or doxycycline or clindamycin are the best treatment options. Chloroquine remains the treatment of choice for all other malaria species, with the exception of P vivax acquired in Indonesia or Papua New Guinea, in which case atovaquone-proguanil is best, with mefloquine or quinine plus tetracycline or doxycycline as alternatives. Quinidine is currently the recommended treatment for severe malaria in the United States because the artemisinins are not yet available. Severe malaria occurs when a patient with asexual malaria parasitemia, and no other confirmed cause of symptoms, has 1 or more designated clinical or laboratory findings. The only adjunctive measure recommended in severe malaria is exchange transfusion.

CONCLUSIONS

Malaria remains a diagnostic and treatment challenge for US clinicians as increasing numbers of persons travel to and emigrate from malarious areas. A strong evidence base exists to help clinicians rapidly initiate appropriate therapy and minimize the major mortality and morbidity burdens caused by this disease.

Report of a case of congenital malaria Plasmodium malariae in France

Congenital malaria (CM) has been considered to be rare, even in malaria-endemic areas but the disease can result in significant neonatal morbidity. Because of its rarity, the disease may go undiagnosed for a prolonged period in a seriously ill infant. We report the first case of Plasmodium malariae CM from a HIV mother. HIV could have facilitated the transfer of erythrocytic persistent P. malariae through the placenta to the fetus.

Congenital malaria in Thailand, an appraisal of previous cases

BACKGROUND

Malaria is an important vector-borne infectious disease. Many tropical countries are the endemic area of malaria. Thailand, a tropical country in Southeast Asia, is the well-known endemic area for malaria. Although Thailand has a high prevalence of malaria, few cases of congenital malaria were reported in the past.

METHODS

Here, the author performed a literature review of the reports of congenital malaria in Thailand in order to summarize the characteristics of this infection among Thai patients.

RESULTS

According to this study, there have been at least six reports in the literature of 27 cases of congenital malaria infection in the Thai population, of which no case was lethal. There were 22 vivax (81.5%) and five falciparum (18.5%) malarial cases. The details on clinical presentations of these cases are presented and discussed.

CONCLUSION

According to this study, it can be seen that congenital malaria may occur in the absence of clinical symptoms in mothers as well as their children. Concerning the species of malaria, the vivax malaria is more common in this case series.

Neonatal malaria in Nigeria--a 2 year review

Background

In view of the fact that a significant proportion of neonates with malaria may be missed on our wards on the assumption that the disease condition is rare, this study aims at documenting the prevalence of malaria in neonates admitted into our neonatal ward. Specifically, we hope to describe its clinical features and outcome of this illness. Knowledge of these may ensure early diagnosis and institution of prompt management.

Methods

Methods Hospital records of all patients (two hundred and thirty) admitted into the Neonatal ward of Olabisi Onabanjo University Teaching Hospital, Sagamu between 1st January 1998 and 31^st December 1999 were reviewed. All neonates (fifty-seven) who had a positive blood smear for the malaria parasite were included in the study. Socio-demographic data as well as clinical correlates of each of the patients were reviewed. The Epi-Info 6 statistical software was used for data entry, validation and analysis. A frequency distribution was generated for categorical variables. To test for an association between categorical variables, the chi-square test was used. The level of significance was put at values less than 5%.

Results

Prevalence of neonatal malaria in this study was 24.8% and 17.4% for congenital malaria.

While the mean duration of illness was 3.60 days, it varied from 5.14 days in those that died and and 3.55 in those that survived respectively. The duration of illness significantly affected the outcome (p value = 0.03). Fever alone was the clinical presentation in 44 (77.4%) of the patients. Maturity of the baby, sex and age did not significantly affect infestation. However, history of malaria/febrile illness within the 2 weeks preceding the delivery was present in 61.2% of the mothers. Maternal age, concurrent infection and duration of illness all significantly affected the outcome of illness. Forty-two (73.7%) of the babies were discharged home in satisfactory condition.

Conclusion

It was concluded that taking a blood smear to check for the presence of the malaria parasite should be included as part of routine workup for all neonates with fever or those whose mothers have history of fever two weeks prior to delivery. In addition, health education of pregnant mothers in the antenatal clinic should include early care-seeking for newborns.

Malaria surveillance--United States, 2004

PROBLEM/CONDITION

Malaria in humans is caused by any of four species of intraerythrocytic protozoa of the genus Plasmodium (i.e., P. falciparum, P. vivax, P. ovale, or P. malariae). These parasites are transmitted by the bite of an infective female Anopheles sp. mosquito. The majority of malaria infections in the United States occur among persons who have traveled to areas with ongoing malaria transmission. In the United States, cases can occur through exposure to infected blood products, congenital transmission, or local mosquitoborne transmission. Malaria surveillance is conducted to identify episodes of local transmission and to guide prevention recommendations for travelers.

PERIOD COVERED

This report summarizes cases in persons with onset of illness in 2004 and summarizes trends during previous years.

DESCRIPTION OF SYSTEM

Malaria cases confirmed by blood film are mandated to be reported to local and state health departments by health-care providers or laboratory staff. Case investigations are conducted by local and state health departments, and reports are transmitted to CDC through the National Malaria Surveillance System (NMSS). Data from NMSS serve as the basis for this report.

RESULTS

CDC received reports of 1,324 cases of malaria, including four fatal cases, with an onset of symptoms in 2004 among persons in the United States or one of its territories. This number represents an increase of 3.6% from the 1,278 cases reported for 2003. P. falciparum, P. vivax, P. malariae, and P. ovale were identified in 49.6%, 23.8%, 3.6%, and 2.0% of cases, respectively. Seventeen patients (1.3% of total) were infected by two or more species. The infecting species was unreported or undetermined in 262 (19.8%) cases. Compared with 2003, the number of reported malaria cases acquired in the Americas (n = 173) increased 17.7%, whereas the number of cases acquired in Asia (n = 172) and Africa (n = 809) decreased 2.8% and 3.7%, respectively. Of 775 U.S. civilians who acquired malaria abroad, only 160 (20.6%) reported that they had followed a chemoprophylactic drug regimen recommended by CDC for the area to which they had traveled. Four patients became infected in the United States; three cases were attributed to congenital transmission and one to laboratory-related mosquitoborne transmission. Four deaths were attributed to malaria, including two caused by P. falciparum, one by P. vivax, and one by a mixed infection with P. falciparum and P. malariae.

INTERPRETATION

The 3.6% increase in malaria cases in 2004, compared with 2003, resulted primarily from an increase in the number of cases acquired in the Americas but was offset by a decrease in the number of cases acquired in Africa and Asia. This limited increase might reflect local changes in disease transmission, increased travel to regions in which malaria is endemic, or fluctuations in reporting to state and local health departments. These changes likely reflect expected variation in annual reporting and should not be interpreted as indicating a longer-term trend. In the majority of reported cases, U.S. civilians who acquired infection abroad had not adhered to a chemoprophylaxis regimen that was appropriate for the country in which they acquired malaria.

PUBLIC HEALTH ACTIONS

Additional investigations were conducted for the four fatal cases and four infections acquired in the United States. Persons traveling to a malarious area should take one of the recommended chemoprophylaxis regimens appropriate for the region of travel and use personal protection measures to prevent mosquito bites. Any person who has been to a malarious area and who subsequently has a fever or influenza-like symptoms should seek medical care immediately and report their travel history to the clinician; investigation should include a blood-film test for malaria. Malaria infections can be fatal if not diagnosed and treated promptly. Recommendations concerning malaria prevention can be obtained from CDC at http://www.cdc.gov/travel or by calling the Malaria Hotline at telephone 770-488-7788. Recommendations concerning malaria treatment can be obtained at http://www.cdc.gov/malaria/diagnosis_treatment/treatment.htm or by calling the Malaria Hotline.

A rare cause of anemia and thrombocytopenia in a newborn: congenital malaria

A newborn with fever and jaundice was referred to our hospital with anemia and thrombocytopenia of unknown origin. The patient's mother suffered from malaria infection during the third trimester of her pregnancy, but she did not accept medical therapy. On physical examination the newborn showed mild splenomegaly and jaundice. Laboratory tests revealed marked anemia with a hemoglobin value of 7.7 g/L and thrombocytopenia with platelet numbers of 17,000/mm3. Plasmodium vivax was detected in blood smear. Oral therapy with chloroquine and primaquine was started. This patient is the second case of congenital malaria reported from Turkey, and shows that the diagnosis of congenital malaria should be considered in infants with suspected congenital infection who are born to mothers with a history of malarial disease. We emphasize the importance of adequate antenatal medical therapy during pregnancy.

[Congenital malaria as a result of Plasmodium malariae in an infant born to a HIV-seropositive woman]

Congenital malaria is uncommon in France. The purpose of this report is to describe a case involving a six-week-old infant who was hospitalized with fever, hepatosplenomegaly, anemia and thrombopenia. Thick and thin blood smears were positive for Plasmodium malariae. The infant responded favorably to chloroquine. Based on this experience, we performed a search of the literature to find case reports on congenital malaria in France and compare clinical and epidemiologic data with series reported in the United States and from endemic areas. The placenta appears to provide an effective barrier against Plasmodium since infection is much more common than disease. The delay for onset of clinical symptoms is longer in temperate zones than in endemic areas. The type of parasite could account for this difference since African congenital malaria are due to Plasmodium falciparum while most cases described in the United States are due to Plasmodium vivax. We also discuss the possible implications of coinfection by HIV in the mother.

Prevalence of congenital malaria in Ile-ife, Nigeria

The study was designed to determine the prevalence of congenital malaria, cord blood and placental malaria parasitaemia and the prevalence of clinical manifestations of congenital malaria. Ile-Ife is a holoendemic area for malaria. Placental, cord and peripheral blood smears of 120 newborn babies were examined for malaria parasites. They consisted of 104 (86.7 per cent) full term babies and 16 (13.3 per cent) preterm babies. Positive parasitaemia was found in 56 (46.7 per cent) of peripheral blood smears, 68 (56.7 per cent) and 65 (54.2 per cent) of the placental and cord blood smears respectively. There were strong associations between placental malaria and cord malaria parasitaemia and congenital malaria (p < 0.001). Congenital malaria has a high prevalence in Ile-Ife. There is a paucity of its clinical manifestations in the newborn. Only two babies had fever within 48 hours of birth.

Centers for Disease Control and Prevention (CDC). Congenital malaria--Nassau County, New York, 2004

Human malaria is a parasitic disease caused by four distinct species of intraerythrocytic protozoa of the genus Plasmodium. The parasites are transmitted to persons by the bite of an infective female Anopheles mosquito and rarely through blood transfusion and congenital transmission. The majority of malarial infections reported in the United States are acquired abroad by recent immigrants or persons returning from areas where malaria is endemic. This report describes the first documented case of congenital malaria acquired in Nassau County, New York, which is the fifth case of congenital malaria reported in the United States since 2000. Health-care providers should consider malaria as a diagnosis in neonates and young infants, particularly those with fever, whose mothers emigrated from areas where malaria is endemic.

Imported malaria at an inner-city hospital in the United States

BACKGROUND

More than 1000 cases of malaria are reported to the Centers for Disease Control and Prevention each year among travelers or immigrants.

METHODS

Retrospective study of patients with malaria seen at Grady Memorial Hospital in Atlanta, Georgia, between October 1988 and September 2000.

RESULTS

One hundred twenty-six cases of malaria were diagnosed at Grady Memorial Hospital during the study period. Fourteen patients had seen a physician prior to coming to Grady Memorial Hospital, and in 71% the diagnosis was missed. Half had recently immigrated and half recently traveled to an endemic area, yet only 22% of travelers took prophylaxis. Plasmodium falciparum was the most commonly identified species (52.4%), followed by Plasmodium vivax (23.9%). Seventy-two patients (57.1%) required hospitalization. Presenting symptoms included fever (94%), chills (56%), nausea/vomiting (38%), headache (26%), and abdominal pain (26%). Most patients were diagnosed correctly on the day of admission (79%). Twelve patients (16.7%) had severe malaria, and their complications included severe anemia (9.7%), acute renal failure (4.2%), bleeding and/or disseminated intravascular coagulation (4.2%), shock (2.8%), seizures (2.8%), and hypoglycemia (2.8%). One patient died, and two pregnant women had premature deliveries. Median hospital stay was 3.9 days. One third of the hospitalized patients with P vivax failed to receive primaquine, and in 15% of patients with P falciparum, the treatment was considered to be inappropriate.

CONCLUSIONS

Although some patients with malaria have a benign course and a good outcome, many patients require hospitalization, and some have severe complications. Increased efforts are needed to educate travelers about the need for prophylaxis.

Changes in haemoglobin levels in infants in Malawi: effect of low birth weight and fetal anaemia

OBJECTIVES

To examine the effect of low birth weight (LBW) and fetal anaemia (FA) on haemoglobin (Hb) patterns in infancy. To study the additional contribution of other risk factors known at birth. To examine the effect of iron supplementation during infancy on Hb levels.

METHODS

A stratified cohort of infants in Malawi (83 with LBW (< 2500 g), 111 with FA (cord Hb < 125 g/l), 31 with both LBW and FA, and 176 controls) was followed during infancy. Hb levels were measured at about 2, 4, 6, 9, and 12 months of age. Repeated measures models were used to describe the changes in Hb levels over time.

RESULTS

The mean Hb concentration in the control group was 95.5 g/l (95% confidence interval (CI) 92.5 to 98.5) at 2 months, 86.9 g/l (95% CI 84.4 to 89.4) at 9 months, and 898 g/l (95% CI 874 to 92.2) at 12 months. Differences between LBW infants and controls increased over time (difference at 12 months: 5.5 g/l (95% CI 1.3 to 9.7)). Infants with FA had borderline significantly lower Hb at 2 months (p = 0.07), but at 6 months their levels were similar to those of controls. The LBW infants and those with FA had the lowest Hb levels (difference from controls at 12 months 7.9 g/l). Parity, placental and maternal malaria at delivery, and sex significantly affected Hb levels after adjustment for LBW and FA. After iron supplementation, Hb significantly increased.

CONCLUSIONS

Antimalarial control and iron supplementation throughout pregnancy should be increased to reduce the incidence of infant anaemia and improve child development and survival.

Congenital malaria in 8 hours old newborn: case report

This report, presents a case of congenital malaria in an 8-hour-old female neonate. She responded well to oral chloroquine at a dose of 25 mg/kg in divided doses over a period of three days and was discharged home for follow-up, 24 hours after completion of the course of chloroquine. This case emphasized the need for routine screening for malaria in sick newborn infants in malaria endemic regions. This is particularly important in situations where clear evidence of sepsis cannot be established, either from history or physical examination of the sick newborn. Malaria and sepsis have similar clinical features in newborn infants.

Centers for Disease Control and Prevention (CDC). Congenital malaria as a result of Plasmodium malariae--North Carolina, 2000

Congenitally acquired malaria is rare in the United States; < or = 10 cases are reported each year. Congenital infection with Plasmodium malariae is particularly uncommon because distribution of this parasite is focal and sparse in areas where P. falciparum is endemic. The last case of congenital P. malariae infection in the United States was reported in 1992. This report describes the investigation of a case of P. malariae in an infant with no travel history outside of the United States and suggests that health-care providers suspect malaria when treating a neonate or young infant with fever if the mother has traveled or lived in a malarious area.

Chloroquine prophylaxis, iron/folic-acid supplementation or case management of malaria attacks in primigravidae in western Uganda: effects on congenital malaria and infant haemoglobin concentrations

A randomized, double-blind, placebo-controlled trial, which compared the effects of three interventions (weekly chloroquine prophylaxis, daily iron and weekly folic-acid supplementation, and case management of malaria) on congenital malaria, maternal haemoglobin (Hb) and foetal outcome, was conducted among primigravidae resident in Hoima district, Uganda. Among 473 babies examined at birth or within 7 days of birth, 198 (42%) were parasitaemic, the level of parasitaemia in an infant being strongly correlated with those of placental (P< 0.01) and maternal, peripheral parasitaemia (P < 0.01). However, 33 (17%) of the parasitaemic babies were born to mothers who had placental but not peripheral parasitaemia, 22 (11%) to mothers who had peripheral but not placental parasitaemia, and 12 (6%) to mothers with neither peripheral nor placental parasitaemia. Overall, 163 babies were each examined for malarial parasites at birth and 1 month later. Of the 76 (47%) found to have parasitaemia at birth, 37 (23%) appeared aparasitaemic at the 1-month follow-up but 28 (17%) were still parasitaemic at that time. Among the babies born to the mothers who only received case management of malaria during pregnancy, parasitaemia at birth was associated with infant anaemia at birth (i.e. < 140 g Hb/litre; P = 0.03). Infants found to be parasitaemic at the 1-month follow-up had lower mean concentrations of Hb at that time than their aparasitaemic counterparts (P= 0.03). Parasitaemia at birth was not significantly associated with low birthweight, in any of three intervention groups. The intervention given to the mother had no significant effect on the parasitaemia of her baby, either at birth or at the age of 1 month. Congenital malaria per se may have little influence on birthweight but may have an impact on infant anaemia. In conclusion, congenital parasitaemia was not associated with birthweight, but was related to anaemia at birth in infants born to women who had only received active case management during their pregnancies.

The potential utility of the Semi-Nested Multiplex PCR technique for the diagnosis and investigation of congenital malaria

We report three cases of congenital malaria involving two malarial immune mothers living in Spain. Diagnostic PCR and Genotyping PCR for merozoite surface proteins 1 and 2 were essential to show that mothers and new-borns had different Plasmodium population parasites at the moment of the delivery, and that the infection was acquired earlier in gestation by transplacental transmission. In the first case the Plasmodium species founded in both, mother and child were different. Malaria in the twins showed a mixed infection (P. falciparum plus P. malariae) while the mother presented a P. falciparum infection. These facts were confirmed studying the polymorphisms for MSP1 and MSP2. Blood samples of the newborns were analyzed an half hour after delivery excluding the possibility of re-infection by mosquito bite and indicating a vertical transmission during pregnancy.

Scant parasitemia in BALB/c mice with congenital malaria infection

Balb/c mice were examined to determine whether or not they transmitted rodent malaria, Plasmodium berghei, to their fetuses. On the 15th day of pregnancy, mice were inoculated with approximately 3 x 10(6) P. berghei-infected erythrocytes by peritoneal injection. The blood from 27 adult females and 196 neonates was examined using a sensitive polymerase chain reaction (PCR) method with a detection level of approximately 1 parasite/microl blood. The average parasitemia of females at delivery was 8.1%, ranging from nondetectable to 37.1%. In 12 females, nested PCR established the presence of blood parasite DNA. Malaria parasites were microscopically confirmed in 2 of the 12 neonates. Maternal parasitemia at the time of delivery was not correlated with the incidence of vertical infection (6.1%), which was higher in this study than that found in previous studies. Although the combination of balb/c mice and P. berghei has not been used to examine vertical transmission of malaria, our report showed that this model may be used for this purpose.

Detection of congenital malaria by polymerase-chain-reaction methodology in Dar es Salaam, Tanzania

The examination of congenital malaria was performed by Giemsa staining and polymerase-chain-reaction (PCR) methodology. We randomly selected 298 neonates who had been admitted to Muhimbili Medical Center (MMC) at Dar es Salaam, Tanzania. One baby among all the enrolled neonates was recognized as having a congenital malaria infection, which gave a prevalence of 0.33%. The present result was 5-fold the clinically recognized prevalence of congenital infection with malaria in the ward. The PCR method identified two cases, one of which was negative as determined by the Giemsa-staining method. Therefore, the PCR method was useful for the detection of scant amounts of malarial parasites in numerous blood samples. The screening of malaria by a sensitive PCR method contributes to reduce the mortality of asymptotic neonates in particular.

[Congenital malaria due to Plasmodium falciparum and Plasmodium malariae]

Increasing tourism and growing numbers of immigrants from malaria-endemic countries are leading to a higher importation rate of rare tropical disorders in European countries. We describe, to the best of our knowledge, the first case of connatal malaria in Austria. The patient is the first child of a 24 year old mother who was born in Ghana and immigrated to Austria one and a half years before delivery. She did not stay in an endemic region during this period and did not show fever or any other signs of malaria. The boy was healthy for the first six weeks of his life. In the 8th week of life he was admitted to our hospital due to persistent fever of unknown origin. On physical examination he showed only mild splenomegaly. Routine laboratory testing revealed mild hemolytic anemia with a hemoglobin value of 8.3 g/l. In the blood smear Plasmodium falciparum and Plasmodium malariae were detected. Oral therapy with quinine hydrochloride was successful and blood smears became negative for Plasmodia within 6 days. This case shows that congenital malaria can occur in children of clinically healthy women who were born in malaria-endemic areas even one and a half year after they have immigrated to non-endemic regions.

[Congenital malaria. Parasitological and serological studies in Niamey (Niger)]

Congenital malaria is defined as the presence of Plasmodium parasites in the erythrocytes of newborns less than seven days old. The aim of this study was to determine the incidence of congenital malaria and its possible clinical consequences. We carried out a prospective survey in Niamey, the capital of Niger (600,000 inhabitants) from July to September 1993. Niamey is in an area of mesoendemic malaria and this period of the year corresponds to the rainy season, when malaria transmission is maximal. Ninety mothers and their newborns were included. We assessed the clinical status of the mother and child at the time of the delivery, and took blood smears to check for parasitemia and blood samples to check for antimalaria antibodies by indirect immunofluorescence (IIF). The placenta was not examined. Clinical signs of malaria (fever, splenomegaly, anemia and jaundice) were absent in all mothers and children and 88 of the 90 children had normal birth weights. Plasmodium falciparum was the only parasite detected, with 49 of the 90 mothers and 12 of the 90 newborns having positive blood smears. Serological tests detected the presence of antimalaria antibodies in 73 of the 90 mothers (81.1%) and 68 of the 90 newborns (75.5%). Thus, we found no cases of congenital malaria with clinical signs in this study, despite the high frequency of parasites and antimalaria antibodies. The reasons for this absence of cases of congenital malaria with symptoms are discussed.

[Congenital malarial disease due to Plasmodium falciparum in high-infection-risk newborn]

The aim of this work was to differentiate in an endemic area congenital malaria diseases (CMD) from congenital malaria infestations (CMI) or other maternal-fetal infections.

METHODS

Four hundred and seventy-five newborn (0-7 d) suspected of infection were prospectively studied. CMD was diagnosed when clinical manifestations were associated with positive thick and thin blood films in a mother and her newborn. The diagnosis of CMI was retained when despite positive parasitemia, no clinical manifestations were observed.

RESULTS

Forty newborns (1.7% of the cases of maternal malaria) were diagnosed as CMD and ninety-one (19% of live births) were considered as CMI. The main clinical manifestations were related to cerebral (100%), respiratory (95%) and hemodynamic (90%) systems. Hematologic signs were present in 95% of cases. The level of parasitemia varied from 700 to 3,000 parasites/mL in CMD and from 360 to 870 parasites/mL in CMI. Death occurred in ten cases (25%) of CMD.

CONCLUSION

In this malaria-endemic area, neither clinical manifestions nor parasitemia allow one to distinguish CMD from CMI associated with bacterial materno-fetal infections. Studying placental or systemic immunity and antimalaria IgM in the newborn could be of interest to clarify this problem.

[Malaria in the infant in a rural area of maritime Guinea (Guinea Conakry). I. Immune and parasitic status of the mother and the newborn]

Among 216 women who had given birth in the rural health maternity centre of Maférinyah (Guinea), 32% had parasitemia with no clinical signs. Antimalarial antibodies could be measured only for 156 women and were present in all of them. Serological antimalarial tests were carried out on 133 newborns, all of whom had antibodies. The serological results of 122 mother infant pairs are given in this article. The absence of parasitemia in 122 newborns confirms the rarity of congenital malaria and would seem to favour the protective role of transmitted maternal antibodies.

Congenital malaria: an African survey

Even in malaria-endemic areas, congenital malaria has been considered to be rare. Some recent reports suggest, however, that up to one fourth of newborns in some areas may be parasitemic. In an effort to determine current prevalence rates of congenital malaria, malaria smears were done on peripheral blood from 100 peripartum mothers and on cord blood from their offspring at each of seven sites spanning sub-Saharan Africa. The prevalence rate of maternal parasitemia was 15% overall and varied from 4% to 30% at the different sites. Congenital malarial infection was found in 7% of newborns, the prevalence rate varying from 0% to 23% at the different sites. There was no apparent relationship between the season of sampling and either the prevalence rates of parasitemia or the penetrance of malaria from mother to offspring. In summary, congenital malarial infection is not rare in sub-Saharan Africa, but the prevalence rate of neonatal parasitemia varies from site to site.

Malaria surveillance--United States, 1993

PROBLEM/CONDITION

Malaria is caused by infection with one of four species of Plasmodium (P. falciparum, P. vivax, P. ovale, and P. malariae), which are transmitted by the bite of an infective female Anopheles sp. mosquito. Most malaria cases in the United States occur among persons who have traveled to areas (i.e., other countries) in which disease transmission is ongoing. However, cases are transmitted occasionally through exposure to infected blood products, by congenital transmission, or by local mosquito-borne transmission. Malaria surveillance is conducted to identify episodes of local transmission and to guide prevention recommendations.

REPORTING PERIOD COVERED

Cases with onset of illness during 1993.

DESCRIPTION OF SYSTEM

Malaria cases confirmed by blood smear are reported to local and/or state health departments by health-care providers and/or laboratories. Case investigations are conducted by local and/or state health departments, and the reports are transmitted to CDC.

RESULTS

CDC received reports of 1,275 cases of malaria in persons in the United States and its territories who had onset of symptoms during 1993; this number represented a 40% increase over the 910 malaria cases reported for 1992. P. vivax, P. falciparum, P. ovale, and P. malariae were identified in 52%, 36%, 4%, and 3% of cases, respectively. The species was not determined in the remaining 5% of cases. The 278 malaria cases in U.S. military personnel represented the largest number of such cases since 1972; 234 of these cases were diagnosed in persons returning from deployment in Somalia during Operation Restore Hope. In New York City, the number of reported cases increased from one in 1992 to 130 in 1993. The number of malaria cases acquired in Africa by U.S. civilians increased by 45% from 1992; of these, 34% had been acquired in Nigeria. The 45% increase primarily reflected cases reported by New York City. Of U.S. civilians who acquired malaria during travel, 75% had not used a chemoprophylactic regimen recommended by CDC for the area in which they had traveled. Eleven cases of malaria had been acquired in the United States: of these cases, five were congenital; three were induced; and three were cryptic, including two cases that were probably locally acquired mosquito-borne infections. Eight deaths were associated with malarial infection.

INTERPRETATION

The increase in the reported number of malaria cases was attributed to a) the number of infections acquired during military deployment in Somalia and b) complete reporting for the first time of cases from New York City.

ACTIONS TAKEN

Investigations were conducted to collect detailed information concerning the eight fatal cases and the 11 cases acquired in the United States. Malaria prevention guidelines were updated and disseminated to health-care providers. Persons who have a fever or influenza-like illness after returning from a malarious area should seek medical care, regardless of whether they took antimalarial chemoprophylaxis during their stay. The medical evaluation should include a blood smear examination for malaria. Malaria can be fatal if not diagnosed and treated rapidly. Recommendations concerning prevention and treatment of malaria can be obtained from CDC.

A recent case of congenital malaria in Singapore

We report a case of congenital malaria in a 2-month-old baby girl, born in Singapore of a Singaporean mother, who presented with fever for one week, gross hepatosplenomegaly and anaemia (haemoglobin 5.6 g/dL) and thrombocytopenia. Peripheral blood films showed Plasmodium vivax. There was no local transmission at that time, but the mother had spent the first 6 months of her pregnancy in Pakistan, where she had been treated for prolonged fever at 4 months amenorrhoea with ibuprofen alone. The mother and 2 siblings were asymptomatic and repeatedly tested negative on blood films for malaria parasites, but the mother tested positive for antibodies to Plasmodium on the Fluorescent Antibody Test. The child was treated with oral chloroquine and made an uneventful recovery. We postulate that this is believed to be the first recent case of congenital malaria in Singapore since it was declared malaria free in 1982. The diagnosis should be considered in babies of mothers who have travelled to places where malaria is endemic, as maternal infection may be unrecognised, and the child may be asymptomatic at birth.

Wistar rat-Plasmodium berghei model does not approximate human congenital malaria

Until recently, congenital malaria was thought to be rare. Now, several reports suggest that more than 10% of newborns in some settings are parasitemic. The pathophysiology of transplacental transmission of Plasmodium is not well understood, and no animal model of congenital malaria exists. A rodent model of malaria in pregnant females, however, has been developed. In an effort to test the usefulness of this model in the study of congenital malaria, Wistar rats were injected intraperitoneally with approximately 10(6) NYU-2 strain Plasmodium berghei-infected erythrocytes at various times relative to conception. Perinatal maternal and neonatal blood was tested for the presence of parasites. Two rats infected preconceptually, 1 at 29 and the other at 11 days prior to mating, delivered aparasitemic pups. Fourteen rats were inoculated during gestation. Five of 5 rats infected on the fifth gestational day succumbed prior to delivery; 1 fetus was parasitemic. Offspring of females infected on the 9th, 10th, 12th, and 14th days of gestation were aparasitemic at birth. Four rats conceived after an initial Plasmodium infection had waned and were reinfected during pregnancy; none of their pups showed evidence of parasitemia. Thus, though rare, transplacental passage of malaria parasites can occur in rats. The Wistar rat-P. berghei model of gestational malaria, however, does not seem to be useful for the study of congenital malaria.

A study of malaria parasitaemia in pregnant women, placentae, cord blood and newborn babies in Lagos, Nigeria

The peripheral blood of 101 pregnant women at delivery, their 105 new born babies and the corresponding placental, and cord blood smears were examined cross sectionally for malaria parasites, during a 3 month period (May-July, 1986). The average maternal age was 26.3 years. Positive parasitaemia was found in 2.97% of maternal peripheral thick blood films; in 2.94% of placental smears, and in 0.95% of cord blood films. Congenital malaria did not occur in the babies.

Materno-fetal transmission of pregnancy malaria: an immunoparasitological study on 202 parturients in Maputo

A total of 202 delivering mothers and their newborns were studied with the intention to follow the materno-fetal transmission of malaria. Malaria infection was encountered in 35 cases (17.3%) in which Plasmodium falciparum predominated in peripheral blood while P. malariae predominated on the placental surface. In cord blood P. falciparum was encountered in 1.5% of the cases. There was slightly more maternal infection in rural (23%) than in suburban areas (19%). Less malaria infection was encountered in primiparas than in multiparas and there was similar antibody response in both mothers and their newborns. Anaemia was encountered in 70% of the mothers and in 93% of the newborns. There was no significant correlation between low birthweight of the newborn and malaria parasitaemia in the mother.

Imported malaria in pregnancy: report of four cases and review of management

Malaria is a common infection worldwide. Increased travel by pregnant women makes it likely that physicians in the United States will see cases of malaria in this population. We observed four cases of malaria during pregnancy over an 8-month period at a general hospital in the United States. These cases illustrate the association between pregnancy and severe malaria in the mother and congenital infection in the newborn. We also noted delays in diagnosis because malaria was mistaken for other common illnesses. Therapy was complicated by concerns about the safety of antimalarial agents for the fetus and newborn as well as drug resistance. While chloroquine is safe for use in pregnancy, drug resistance is now common, especially when the etiologic organism is Plasmodium falciparum. There are concerns about the safety of administering other antimalarial agents during pregnancy (e.g., mefloquine). Concerns about the safety and availability of these agents limit options for prophylaxis.