Congenital Malaria in a 20-Day-Old Neonate: A Case Report and Literature Review

Introduction

Congenital malaria refers to the transmission of malaria from an infected mother to her unborn child during pregnancy. This can happen if the mother experiences malaria symptoms during pregnancy, but it can also occur in cases where the mother is asymptomatic, making it difficult to diagnose both in the mother and the newborn.^1,2 It is a rare but serious condition that can result in significant morbidity and mortality in neonates.¹ Plasmodium falciparum is the most prevalent species involved in congenital malaria; however, Plasmodium vivax and Plasmodium malariae can also be involved.²

It is a rare condition that should be included in the differential diagnosis of neonatal infections, sepsis, unexplained fever, or infants presenting with hemolytic anaemia, jaundice, or hepatosplenomegaly in malaria endemic zones.³ Early diagnosis is essential for prompt treatment and may prevent an unfavorable outcome. Early diagnosis of congenital malaria includes the availability and accuracy of diagnostic tests, as well as the potential for false-negative results. Additionally, some infants may not show symptoms of infection until several weeks after birth, which can delay diagnosis and treatment. In general, early diagnosis of congenital malaria involves screening pregnant women for malaria infection, testing newborns for congenital malaria, monitoring for symptoms, and promptly treating any positive cases.^3–5 Here we present a case of a neonate with congenital malaria.

Case Presentation

This is a 20-day-old male neonate who was born to a 22-year-old para-I (woman who has been delivered of a child for the first time) mother from Western Ethiopia. The mother had four antenatal care (ANC) contacts at the health center. The mother had received routine care during pregnancy, including the tetanus vaccine, deworming, iron supplementation, and nutritional advice. But she was not provided with insecticide treated mosquito nets. During the index pregnancy, the mother had attacks of malaria in the 3^rd, 5th, and 8^th months of gestation. She was treated with artemether/lumefantrine as an outpatient. The mother had no history of urinary tract infections, sexually transmitted infections, or other chronic medical problems.

After nine months of amenorrhea, the mother presented to the nearby health center with labour pain. She was evaluated and admitted with the active phase of the 1^st stage of labour. The labour progressed smoothly, and she gave birth vaginally to a male, alive neonate with good conditions. The neonate received basic newborn care. Breastfeeding was initiated within one hour of delivery. On the next day, the mother and the neonates were discharged from the health center with good conditions and the necessary advice.

On the 20^th day postpartum, the neonate presented to the nearby Health center with vomiting, and a high-grade fever for one day. However, the neonate had no history of fast breathing, no history of abnormal body movement, and no history of yellowish discoloration of the eyes and skin. At the Health Centre, blood film (BF) was done and showed trophozoite of P. vivax. Then, the patient was referred to Wallaga University Referral Hospital for further evaluation and management after paracetamol suppository was inserted for the high-grade fever.

On examination, the neonate was acutely sick-looking. His vital signs were pulse rate (PR) = 160 beats per minute, respiratory rate (RR) = 48 breaths per minute, a temperature of 37.6°C, oxygen saturation = 96%, weight = 3000 grammes, height = 53 centimeters, and head circumference = 36 centimeters. He had pink conjunctiva. The neonate had Splenomegaly (Spleen was palpable 2cm along its line of growth). The lymph glandular system, respiratory system, cardiovascular system, and genitalia were normal. On neurologic examination, all the neonatal reflexes were intact. At Wallaga University Referral Hospital, blood film (BF) was repeated and showed trophozoites stage of Plasmodium vivax with a parasite density of +3. parasite density means that there are a large number of parasites present in the blood sample, indicating a severe infection. The scale ranges from 0 to 4+, with 0 indicating no parasites seen and 4+ indicating a very high number of parasites present in the blood. Neonate had severe thrombocytopenia (49,000/micro liter) (Table 1).

Table 1 Laboratory Investigation Results of a 20-Day-Old Neonate at Wallaga University Referral Hospital, Western Ethiopia, 2023

With the final diagnosis of congenital malaria, the neonate was admitted with congenital malaria and treated with artesunate 3mg/kg IV at admission, 12 hours later, 24 hours later, and then daily for five days. On the sixth day, the neonate showed significant improvement and was discharged with advice on prevention of malaria and postpartum follow-up.

Discussion

Malaria is a parasitic disease that is spread by female Anopheles mosquitoes during their blood meals. It is caused by a protozoan parasite belonging to the genus Plasmodium, which has five different species. In this particular case report, the neonate was diagnosed with P. Vivax as the underlying cause of malaria. Congenital malaria is a rare condition where the plasmodium parasite is transmitted from the mother to the fetus during pregnancy. It is important to note that the onset of signs may be delayed. This delay can be attributed to several factors, including the transmission of the infection in late pregnancy or during delivery, or the presence of maternal antibodies (IgG) that were acquired trans placentally. In cases where the mother has been infected with malaria during pregnancy, the parasite can cross the placenta and infect the fetus. This can occur at any stage of pregnancy, but it is more likely to happen in the later stages. The presence of maternal antibodies (IgG) acquired trans placentally can also play a role in delaying the onset of signs in newborns with congenital malaria. These antibodies can provide some protection against the infection, but they may not be enough to prevent the development of signs in all cases.^5–9 In our case, the neonate presented to the health center within a day of onset of the signs, and the diagnosis was made on arrival. The referral to a better facility and initiation of treatment were completed on time. This early diagnosis and treatment might explain the good outcome.

Congenital malaria occurs when the mother has an active malaria infection during pregnancy, and the parasite crosses the placenta and infects the fetus.⁶ In our case, the mother of the neonate had repeated attacks of malaria during pregnancy at the 3^rd, 5th, and 8^th months of gestation.

Congenital malaria can be difficult to diagnose because the signs are nonspecific and might mimic other neonatal infections. However, Presence of fever, anemia, and splenomegaly is a pointer towards congenital malaria.¹⁰ In our case, the neonate presented with vomiting, and a high-grade fever of one day duration and the neonate had splenomegaly (spleen was palpable 2cm along its line of growth). CBC result also indicates severe thrombocytopenia (49,000/micro liter). At the same time the mother had repeated malaria attack during the index pregnancy. Therefore, malaria endemic areas or travel histories, a high index of suspicion is very important to diagnose malaria, as noted in this case. Therefore, we highlight the importance of considering congenital malaria as a differential diagnosis of neonatal sepsis in neonates born to mothers from malaria endemic areas, with travel history, or with a history of malaria attack during pregnancy.

Prevention of congenital malaria is essential. It can be prevented by using insecticide-treated bed nets and protective clothing, and by prompt diagnosis and treatment of malaria in pregnant women.^6,8,10 In our case, the mother was not provided with insecticide treated bed nets. This led her to have repeated attacks of malaria, which were treated with artemether/lumefantrine.

Conclusion

In conclusion, congenital malaria is a serious condition that can have detrimental effects on newborns. It is important to note that newborns born to mothers in malaria-endemic areas or who have a history of malaria attack(s) during pregnancy are at a higher risk of developing congenital malaria. Therefore, sick neonates born to mothers in malaria-endemic areas or history of malaria attack(s) in the index pregnancy should be promptly investigated for malaria.