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Medical History:  A 25-year-old female outpatient presenting with fever and micro-hematuria was treated for urinary tract infection. Her condition worsened over 3 days at home. After experiencing multiple falls caused by leg weakness and mental confusion, she was admitted to a hospital with high fever., Diagnostics:  Initial laboratory findings showed hemolytic anemia, pancytopenia, and acute kidney injury, suggesting hemolytic uremic syndrome. However, a detailed fever evaluation revealed her recent return from Afrika. This prompted a malaria test, which confirmed Plasmodium falciparum infection with 80 % parasitemia., Therapy and Progress:  Despite the quick reduction of parasitemia following treatment with intravenous administered artesunate and oral Artemether-Lumefantrine, her condition worsened, leading to a septic shock. This required renal replacement and kinetic ventilation therapy, as well as blood transfusions due to persistent hemolysis until the laboratory values normalized after 48 days post-admission., Conclusion:  The evaluation of fever is often challenging, but most often a detailed patient history is key to early diagnosis and treatment preventing deathly outcomes in severe cases., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

From 1993 to 2007, a total of 11,605 malaria cases were reported to the Robert Koch-Institut. For 9 593 of these cases information on the possible country of infection is available. Analysis of the data indicates that the malaria cases were imported to Germany from 96 countries. The majority of the malaria cases were acquired in Africa, followed by distinctly fewer cases from Asian countries. More than half of all cases were imported from only 6 countries (Ghana, Kenya, Nigeria, Cameroon, Gambia, and India). The number of cases imported from, e.g., Kenya and India has declined, whereas infections from Ghana, Nigeria, and Cameroon have increased during the last years. For more than two-thirds of all infections the predominant parasite species was P. falciparum; this is consistent with the predominance of the African continent as the main source of infection.

History: A 52-year-old woman was hospitalized with fever after a 3-week stay in tropical Kenya. Prophylaxis against malaria had been carried out with chloroquine., Diagnosis: Falciparum malaria with 28% parasitaemia at first examination, rising to 50% after 3 hours., Treatment and Course: Treatment with quinine dihydrochloride i.v. was initiated immediately after diagnosis. In addition, in view of increasing parasitemia of up to 50%, a partial exchange blood transfusion was carried out. No clinical signs of organ damage caused by malaria were observed. Because of a drop in blood pressure the patient needed catecholamine treatment for a short time. After decrease of the parasitemia the patient rapidly recovered and complete cure was achieved., Conclusion: Despite extremely high parasitemia the clinical signs were unusually mild. Standard treatment for severe malaria is intravenous administration of quinine. However, this drug is no longer sold in Germany, so that difficulty in obtaining it must be expected. A stockpiling of quinine is recommended for hospitals treating patients with malaria. Transfusion may improve outcome and must be considered if parasite counts are high or if there are clinical signs of malaria complications.

History and Admission Findings: A 56-year-old man was admitted to the hospital 11 days after returning from Kenya because of recurrent fever attacks. The patient had not taken malaria chemoprophylaxis and had previously received symptomatic treatment for suspected viral infection by his general practitioner. Physical findings on admission included enlargement of liver and spleen, marked dehydration and a body temperature of 40.1 degrees C., Investigations: Initial chest radiography showed no abnormalities. Thick and thin blood smears were positive for Plasmodium falciparum. Initial parasitemia was 0.5 per thousand., Treatment and Course: Despite immediate quinine therapy including loading dose and intensive care treatment complicated malaria with multiorgan failure developed. The patient required mechanical ventilation, high-dose catecholamine treatment and hemodialysis for several days. The course of parasitemia peaked on treatment day 2 at a level of 31.1 per thousand., Conclusion: Our case shows serious consequences and important complications of Plasmodium falciparum malaria in a patient without chemoprophylaxis and with delayed diagnosis. Fever following a stay in the tropics requires immediate testing for malaria infection.

WHO recommendations have adopted the option of stand-by emergency treatment (SBT) for travellers to areas where malaria is endemic and medical attention may not be obtained within 24 hours after onset of symptoms. Indication and choice of drugs for SBT depend on use and kind of a chemoprophylactic regimen, situation of plasmodial resistance at the destination, and contraindications and tolerability in the individual traveller. However, the diagnosis of malaria on clinical grounds alone is unreliable, and fever occurs frequently during travel to malaria endemic areas from various reasons. The possibility of malaria has to be considered in all cases of unexplained fever that starts after the 7th day of stay in an endemic area. Studies in European travellers have shown that only 0.5-1.4% of all travellers to whom SBT medication has been prescribed, will finally use it. SBT use in febrile travellers (8.1-10.4% of all travellers) has been 4.9-17%, but plasmodial infection could be confirmed retrospectively in 10.8-16.7% of SBT-users only. The recent introduction of rapid diagnostic tests (RDT) for malaria has provided a potential tool to self-diagnose and treat a possible malaria attack when medical attention or microscopic diagnosis is not available. However, the utilisation of currently available RTDs by travellers has been shown to be technically problematic. Healthy volunteers were able to learn how to perform the tests, especially when standard written instructions were supplemented with verbal information (75 vs. 90% successful performance). But their interpretation of test results was unsatisfactory, with a high rate of false-negatives (14.1%). In another study in febrile European tourists in Kenya, only 68% of patients were able to perform the RDTs correctly, and 10 out of 11 with microscopically confirmed malaria failed to diagnose themselves accurately. Thus, besides appropriate training before departure, technical improvements are required before such RDT kits can be recommended for self-use by travellers.

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.

We report on a five month-old infant from Cameroon, who was admitted because of febrile gastroenteritis after living in Germany for two weeks. Since the patient was somnolent, had a parasitaemia of Plasmodium falciparum of 230,000/microliter, a haemoglobin concentration of 5.3 g/dl and a thrombocytopenia, a complicated falciparum malaria was diagnosed. Treatment was started immediately with intravenous 20 mg quinine/kg bw as a loading dose, followed by 10 mg/kg bw every 12 hours, combined with intravenous clindamycin 10 mg/kg bw bd. Red blood cells were transfused once. The parasitaemia dropped to 2000 trophozoites/microliter within 48 hours. No asexual stages were detectable from the third day of treatment on. Weekly controls for the following four weeks remained negative. The mortality rate of complicated malaria is 50% in the first year of life, which can be reduced by early treatment. We present this case to draw attention to therapeutic options in infants.

Suspected tropical malaria is an acute emergency. Immediate effective pharmacological treatment is of the essence. As in the case of prevention, various antimalarials are now available for treatment. Complicated tropical malaria requires treatment in hospital and intensive monitoring. The risk of infection and serious illness leading to a fatal outcome can be considerably reduced by suitable chemoprophylaxis or the use of stand-by medication for self-treatment, which, however, must be matched to resistance zones and the incidence of the four species of Plasmodium, in particular Plasmodium falciparum.

This is a case report of a 24 year-old woman who is HIV-infected since three years (stage III B, CDC). She developed malaria tropica during her touristic stay in the Cameroons, Africa. No clinical complications were detectable even though she had a high parasitemia of 18% blood cells infected with Plasmodium falciparum. After quinine therapy defervescence occurred and blood smears were continuously free of malaria parasites. P. falciparum infection may increase HIV-related immunosuppression which favours the earlier occurrence of AIDS indicative opportunistic infections. Malaria in combination with HIV-infection can lead to a higher parasitemia; this does not necessarily lead to a higher rate of complications.

Plasmodium falciparum is the predominant plasmodium species in Africa south of the Sahara to a proportion of 80% and more. Two thirds of all cases of malaria in Switzerland are imported from Africa. Accordingly, malignant malaria is more frequently diagnosed in Switzerland than tertian malaria. Malignant malaria usually presents atypically, e.g. as acute gastrointestinal disease or as shock. The lethality is high. The majority of Swiss travellers are not protected effectively against malaria. A group particularly at risk are tourists of 20--30 years of age. It is suggested that travel agencies, official bodies and the medical profession should intensify public information regarding the dangers and prevention of malaria.

After arriving in Austria a 10 month old Nigerian infant fell sick with malaria tropica and survived after specific antiparasitic therapy. Early diagnosis and immediate begin of treatment are stressed.

Malaria is not a disease of the past. As long as worldwide eradication has not been achieved there is a close connection between countries which export it and those which import it. If the European doctor is presently confronted with a feverish disease which may have been brought in from a tropical area, he should immediately think of malaria and take the necessary measures for treatment. If patients or travelers come into the office and enquire about drugs and preventive measures against malaria, the doctor must choose the correct methods. This is best done by two questions: Where have you come from? and Where are you going? In this way the doctor can obtain ideas on the possibility of resistant strains of parasite in the region in question. Tourists should not forget that a rational and regular chemoprophylaxis is the best protection against serious attacks of malaria.