Trop Med Int Health. 1999 Jul;4(7):525
Letter to the Editors
'Unexplained death' from malaria tropica mistaken for viral haemorrhagic fever
Sirs, In November 1998, a 32-year-old man travelled to The Gambia as a participant of an organized tourist trip. Eight days after his return to Belgium he developed fever, chills, vomiting, diarrhoea and myalgias. He initially sought medical help, but 5 days later was found dead at home. Because another unexplained death allegedly had occurred in the tourist group, health officials decided to transfer the deceased to the Queen Astrid Military Hospital for autopsy in order to rule out a viral haemorrhagic fever infection.
The body was transported in an air-tight coffin. The autopsy, performed under biosafety level 3 conditions, revealed hepatosplenomegaly and icterus but no haemorrhagic lesions. Blood, liver and spleen samples were packed according to WHO regulations and transported by military aeroplane within 3 h to the Bernhard-Nocht-Institute for Tropical Medicine (BNI) in Hamburg for histopathology, serology, cell culture and biomolecular analysis under BSL 4 conditions. The collaboration between Brussels and Hamburg was organized by the European Network for Imported Viral Diseases (ENIVD), Robert Koch Institute, Berlin, Germany (Niedrig et al. 1998). Preliminary measures were taken to start tracing the patient's contacts, in case the diagnosis of a viral haemorrhagic fever infection were to be confirmed.
Blood smear examination of the autolytic blood sample and histopathology of liver and spleen revealed malaria tropica (Plasmodium falciparum) as the cause of death. PCR and serology excluded Ebola, Marburg, Lassa, Crimean-Congo haemorrhagic fever and Rift valley fever viruses. The bacterial cultures and cell-cultures inoculated with postmortem blood remained negative.
This tragic event demonstrates the importance of excluding malaria in any febrile patient who could be at risk of having contracted the disease. In experienced hands, the first blood smear will reveal parasitaemia in 98% of symptomatic patients (Svenson et al. 1995). However, suspicion of malaria makes repeated blood smears mandatory until the diagnosis is clearly ruled out. Other infectious causes of fever in returned travellers include enteric fevers, rickettsial diseases, leptospirosis, dengue fever and acute schistosomiasis (Magill 1998). The import of viral haemorrhagic fevers, though possible, remains a rare event.
Paul Heyman, J. ter Meulen, M. Roman, H. Schmitz, F. Heyvaert and P. Raczand, C. Vandenfelde
1. Magill AJ (1998) Fever in the returned traveller. Infectious Disease Clinics of North America 12, 445–469.
2. Niedrig M, Niklasson B, Lloyd G et al. (1998) Establishing a European network for the diagnosis of ‘imported’ viral diseases (ENIVD). Eurosurveillance 3, 80.
3. Svenson JE, Gyorkos TW, MacLean JD et al. (1995) Diagnosis of malaria in the febrile traveller. American Journal of Tropical Medicine and Hygiene 53, 518–521.