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Fatal imported case of Plasmodium mixed infection: cerebral malaria, thrombocytopenia and multi organ dysfunctions (MODs)

  • Chiara Angeletti1
  • Sofia Chiatamone Ranieri2
  • Gabriella Di Leonardo2
  • Maria Paola Di Bartolomeo3
  • Nadia Carbuglia1
  • Federica Venturoni1
  • Riccardo Moretti1

1Anesthesiology, Intensive Care and Pain Medicine, Emergency Department of General Civil, Hospital "G. Mazzini" Teramo, 64100 Teramo, Italy

2Laboratory of Clinical Pathology and Microbiology Department of General Civil Hospital "G. Mazzini" Teramo, 64100 Teramo, Italy

3Radiology Department of General Civil Hospital "G. Mazzini" Teramo, 64100 Teramo, Italy

DOI: 10.22514/sv.2021.108 Vol.17,Issue 6,November 2021 pp.145-149

Submitted: 15 February 2021 Accepted: 12 April 2021

Published: 08 November 2021

*Corresponding Author(s): Chiara Angeletti E-mail:


Background: Plasmodium falciparum accounts for nearly all severe malaria cases among European travellers, even though, in areas of endemicity, Plasmodium vivax seems to cause severe malaria to a degree which is comparable with P. falciparum. Furthermore, unlike countries at high risk, the incidence of mixed infections among imported cases is very low. We report the case of a man from non-endemic country with a mixed infection diagnosed after a two-year stay in Guinea.

Case Presentation: A 43-year-old male Italian patient developed hyperpyrexia and chills the day after his return to Italy. Within 7 days from fever onset, he was found unresponsive with vomiting and seizures. On admission to Emergency Room, the patient was hypotonic with flaccid tetraparesis, with a GCS score of 7. On the basis of personal and working history and clinical features, after exclusion of viral encephalitis, acute pyogenic meningitis, tubercular meningitis and pontine infarct, cerebral malaria infection was suspected. Rapid diagnostic test and peripheral blood smear were positive for plasmodium mixed infection (P. falciparum, P. vivax, Plasmodium ovale). Over the first 30 hours from admission, thrombocyte count dropped, and the patient developed disseminated intravascular coagulation. Renal failure required renal replacement therapy. Death occurred after 48 hours of ICU admission.

Conclusion: The fatal course of the severe malaria with related cerebral impairment, lung and kidney failure, disseminated intravascular coagulation, severe acidosis, circulatory collapse with refractory septic shock and subsequent multi organ failure was likely due to delayed medical presentation by the patient and the mixed plasmodium infection. Diagnosis could only be established nine days after onset of symptoms.


Cerebral malaria; P. vivax; MODs; Thrombocytopenia; Plasmodium mixed infection

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Chiara Angeletti,Sofia Chiatamone Ranieri,Gabriella Di Leonardo,Maria Paola Di Bartolomeo,Nadia Carbuglia,Federica Venturoni,Riccardo Moretti. Fatal imported case of Plasmodium mixed infection: cerebral malaria, thrombocytopenia and multi organ dysfunctions (MODs). Signa Vitae. 2021. 17(6);145-149.


[1] World Health Organization. World malaria report 2020. 2020. Avaliable at: 9789240015791 (Accessed: 1 June 2021).

[2] ECDC. Annual epidemiological report for 2015. Stockholm: ECDC. 2017. Avaliable at: (Accessed: 1 June 2021).

[3] Mali S, Kachur SP, Arguin PM. Division of Parasitic Diseases and Malaria, Center for Global Health; Centers for Disease Control and Prevention (CDC). Malaria surveillance—United States, 2010. MMWR Surveill Summ. 2012; 61: 1–17.

[4] Ruas R, Pinto A, Nuak J, Sarmento A, Abreu C. Non-falciparum malaria imported mainly from Africa: a review from a Portuguese hospital. Malaria Journal. 2017; 16: 298.

[5] Naing C, Whittaker MA, Nyunt Wai V, Mak JW. Is Plasmodium vivax malaria a severe malaria? A systematic review and meta-analysis. PLoS Neglected Tropical Diseases. 2014; 8: e3071.

[6] Odolini S, Gautret P, Parola P. Epidemiology of imported malaria in the mediterranean region. Mediterranean Journal of Hematology and Infectious Diseases. 2012; 4: e2012031.

[7] Baird JK. Evidence and implications of mortality associated with acute Plasmodium vivax malaria. Clinical Microbiology Reviews. 2013; 26: 36–57.

[8] Santos LC, Abreu CF, Xerinda SM, Tavares M, Lucas R, Sarmento AC. Severe imported malaria in an intensive care unit: a review of 59 cases. Malaria Journal. 2012; 11: 96.

[9] D’Abramo A, Lepore L, Iannetta M, Gebremeskel Tekle S, Corpolongo A, Scorzolini L, et al. Imported severe malaria and risk factors for intensive care: A single-centre retrospective analysis. PLoS ONE. 2019; 14: e0225135.

[10] Karnad DR, Nor MBM, Richards GA, Baker T, Amin P; Council of the World Federation of Societies of Intensive and Critical Care Medicine. Intensive care in severe malaria: report from the task force on tropical diseases by the world federation of societies of intensive and critical care medicine. Journal of Critical Care. 2018; 43: 356–360.

[11] Al Farsi F, Chandwani J, Mahdi AS, Petersen E. Severe imported malaria in an intensive care unit: a case series. IDCases. 2020; 17: e00544.

[12] Twohig KA, Pfeffer DA, Baird JK, Price RN, Zimmerman PA, Hay SI, et al. Growing evidence of Plasmodium vivax across malaria-endemic Africa. PLoS Neglected Tropical Diseases. 2019; 13: e0007140.

[13] Kondrashin AV, Morozova LF, Stepanova EV, Turbabina NA, Maksi-mova MS, Morozov EN. On the epidemiology of Plasmodium vivax malaria: past and present with special reference to the former USSR. Malaria Journal. 2018; 17: 346.

[14] Commons RJ, Simpson JA, Thriemer K, Hossain MS, Douglas NM, Humphreys GS, et al. Risk of Plasmodium vivax parasitaemia after Plasmodium falciparum infection: a systematic review and meta-analysis. The Lancet Infectious Diseases. 2019; 19: 91–101.

[15] Okafor CN, Finnigan NA. Malaria (Plasmodium ovale). Treasure Island: StatPearls Publishing. 2020.

[16] World Health Organization. Guidelines for the treatment of malaria. Third edn. Geneva: WHO Press. 2015.

[17] Gowda D, Dayananda K, Achur R. Epidemiology, drug resistance, and pathophysiology of plasmodium vivax malaria. Journal of Vector Borne Diseases. 2018; 55: 1–8.

[18] Taylor TE, Fu WJ, Carr RA, Whitten RO, Mueller JS, Fosiko NG, et al. Differentiating the pathologies of cerebral malaria by postmortem parasite counts. Nature Medicine. 2004; 10: 143–145.

[19] Mohanty S, Benjamin LA, Majhi M, Panda P, Kampondeni S, Sahu PK, et al. Magnetic resonance imaging of cerebral malaria patients reveals distinct pathogenetic processes in different parts of the brain. MSphere. 2017; 2: e00193–17.

[20] Dondorp AM, Ince C, Charunwatthana P, Hanson J, van Kuijen A, Faiz MA, et al. Direct in vivo assessment of microcirculatory dysfunction in severe falciparum malaria. The Journal of Infectious Diseases. 2008; 197: 79–84.

[21] Moxon CA, Chisala NV, Mzikamanda R, MacCormick I, Harding S, Downey C, et al. Laboratory evidence of disseminated intravascular coagulation is associated with a fatal outcome in children with cerebral malaria despite an absence of clinically evident thrombosis or bleeding. Journal of Thrombosis and Haemostasis. 2016; 13: 1653–1664.

[22] Miller LH, Ackerman HC, Su X, Wellems TE. Malaria biology and disease pathogenesis: insights for new treatments. Nature Medicine. 2013; 19: 156–167.

[23] Margono S, Lubis B, Pasaribu S, Wijaya H, Pasaribu AP. The correlation between platelet count and parasite density in children with malaria infection. Asian Pacific Journal of Tropical Disease. 2016; 6: 199–203.

[24] Punnath K, Dayanand KK, Chandrashekar VN, Achur RN, Kakkilaya SB, Ghosh SK, et al. Association between Inflammatory Cytokine Levels and Thrombocytopenia during Plasmodium falciparum and P. vivax Infections in South-Western Coastal Region of India. Malaria Research and Treatment. 2019; 2019: 4296523.

[25] White NJ, Pukrittayakamee S, Hien TT, Faiz MA, Mokuolu OA, Dondorp AM. Malaria. Lancet. 2014; 383: 723–735.

[26] Cheng MP, Yansouni CP. Management of severe malaria in the intensive care unit. Critical Care Clinics. 2013; 29: 865–885.

[27] Taylor WRJ, Hanson J, Turner GDH, White NJ, Dondorp AM. Respiratory manifestations of malaria. Chest. 2012; 142: 492–505.

[28] Dai Q, Zhang G, Lai C, Du Z, Chen L, Chen Q, et al. Two cases of false platelet clumps flagged by the automated hematology analyzer Sysmex XE-2100. Clinica Chimica Acta. 2014; 429: 152–156.

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