Congenital malaria in a neonate born in a malaria-endemic area: a case report (original) (raw)

Abstract

Background

Malaria remains a significant public health concern, particularly in Africa, where children under 5 years of age are affected. While mosquito bites are the primary transmission route, congenital malaria caused by transplacental or perinatal transmission can also occur. This case report highlights the challenges in diagnosing congenital malaria and emphasizes the importance of considering it in neonates, especially those born in or with a travel history to endemic areas.

Case presentation

We report a case of congenital malaria in a 48 h-old male neonate born to a 23 year-old Ethiopian primigravida. The mother, who had received antenatal care in a nonendemic area, was diagnosed and treated for uncomplicated Plasmodium falciparum malaria with artemether-lumefantrine (Coartem®) one week before delivery. The delivery occurred at a hospital in a malaria-endemic zone. The neonate presented with respiratory distress and persistent fever, initially managed as early-onset neonatal sepsis. However, blood film microscopy confirmed parasitemia with coinfection of P. falciparum and P. vivax, with a parasite density of 1120 parasites/μL. The mother was asymptomatic at the time of the neonate’s diagnosis and tested negative for malaria by both Rapid Diagnostic Test (RDT) and microscopy. The neonate was successfully treated with intravenous artesunate followed by oral artemisinin-lumefantrine, with complete clinical recovery.

Conclusion

Despite the nonspecific symptoms, this case emphasizes the importance of considering congenital malaria in neonates, particularly those with a history of travel to endemic areas. Blood film microscopy confirmed coinfection and guided effective antimalarial therapy. Strengthening antenatal care services, including intermittent preventive treatment during pregnancy, is recommended to reduce the burden of congenital malaria.

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Background

Malaria remains a major public health challenge globally, particularly in Africa [[1](/article/10.1186/s13256-025-05525-3#ref-CR1 "World Health Organization. Malaria. 2024. https://www.who.int/news-room/fact-sheets/detail/malaria

            ")\]. The World Health Organization (WHO) reports that in 2023 alone, there were an estimated 263 million cases and 597,000 deaths worldwide, with the majority of the burden in the WHO African Region. This region accounted for 94% of all cases and 95% of deaths, with children under 5 accounting for the majority (76%) of the deaths \[[2](/article/10.1186/s13256-025-05525-3#ref-CR2 "World Health Organization. World malaria report 2024: addressing inequity in the global malaria response. Geneva: World Health Organization; 2024."), [3](/article/10.1186/s13256-025-05525-3#ref-CR3 "Li J, Docile HJ, Fisher D, Pronyuk K, Zhao L. Current status of malaria control and elimination in Africa: epidemiology, diagnosis, treatment, progress and challenges. J Epidemiol Glob Health. 2024;14(3):561.")\]. Recently, five countries reported 5 million additional cases between 2021 and 2022, three of which were in Africa, including Ethiopia, Nigeria (+ 1.3 million each), and Uganda (+ 597,000) \[[4](/article/10.1186/s13256-025-05525-3#ref-CR4 "World Health Organization. World Malaria Report 2023. Geneva: World Health Organization. 2023. 
              https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2023
              
            .")\]. In Ethiopia, malaria is a significant public health concern, with an estimated 5 million cases, and 60% of the population living in areas at risk \[[4](/article/10.1186/s13256-025-05525-3#ref-CR4 "World Health Organization. World Malaria Report 2023. Geneva: World Health Organization. 2023. 
              https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2023
              
            ."), [5](/article/10.1186/s13256-025-05525-3#ref-CR5 "Yeshiwondim AK, Gopal S, Hailemariam AT, Dengela DO, Patel HP. Spatial analysis of malaria incidence at the village level in areas with unstable transmission in Ethiopia. Int J Health Geogr. 2009;8(1):5.")\].

The primary causative agents of malaria worldwide are protozoan parasites of the genus Plasmodium, with five species known to infect humans: Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae, Plasmodium ovale, and Plasmodium knowlesi. Among these, P. falciparum and P. vivax are predominant, with P. falciparum being responsible for the most severe manifestations of the disease [5, [6](/article/10.1186/s13256-025-05525-3#ref-CR6 "Crutcher JM, Hoffman SL. Malaria. Medical Microbiology. 1996. https://www.ncbi.nlm.nih.gov/books/NBK8584/

            .")\]. In Ethiopia, more than 99% of malaria cases are attributed to _P. falciparum_ and _P. vivax_, which are transmitted predominantly through the bites of infected female _Anopheles_ mosquitoes. However, mosquito bites are not the only route of transmission \[[7](/article/10.1186/s13256-025-05525-3#ref-CR7 "Buck E, Finnigan NA. Malaria. StatPearls. 2023. 
              https://www.ncbi.nlm.nih.gov/books/NBK551711/
              
            .")\].

Congenital malaria is defined as the identification of asexual forms of the parasite in the peripheral blood of newborns within the first 24 hours to 7 days of life, resulting from in-utero infection or transmission during birth [[8](/article/10.1186/s13256-025-05525-3#ref-CR8 "Ethiopian Federal Ministry of Health. National Malaria Control and Elimination Program. Disease Prevention and Control Directorate. 2018. 43–57 p. www.moh.gov.et

            .")\]. It is rare in countries that are endemic to malaria due to a high level of maternal antibodies \[[9](/article/10.1186/s13256-025-05525-3#ref-CR9 "Mohan K, Omar BJ, Chacham S. Malaria in newborn: a missed entity for primary care physician. J Family Med Prim Care. 2023;12(8):1511.")\]. However, studies have reported that 6.9% of congenital malaria cases are reported throughout the world \[[10](/article/10.1186/s13256-025-05525-3#ref-CR10 "Thapar RK, Saxena A, Devgan A. Congenital malaria. Med J Armed Forces India. 2008;64(2):185.")\]. The diagnosis of congenital malaria presents challenges, often leading to misdiagnosis due to nonspecific clinical manifestations, particularly when it presents alongside neonatal sepsis \[[11](/article/10.1186/s13256-025-05525-3#ref-CR11 "Bilal JA, Malik EE, Al-Nafeesah A, Adam I. Global prevalence of congenital malaria: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2020;252:534–42.")\]. This study reports a case of congenital malaria in an Ethiopian hospital and highlights the importance of considering this rare and critical problem in healthcare settings.

Case presentation

A 48 h-old male neonate born to an Ethiopian mother with respiratory distress was admitted to the neonatal intensive care unit (NICU) at Dil-Fana Hospital in Arba Minch, southern Ethiopia. The mother was a 23 year-old primigravida (G1P1) with no previous history of pregnancies. Her last menstrual period (LNMP) was unknown, but she reported 9 months of amenorrhea. Notably, she received antenatal care (ANC) follow-up at a healthcare facility in the Wolayta zone, an area not endemic for malaria. However, delivery occurred vaginally without complications at our hospital, which is located in an area with high malaria transmission rates. The neonates had APGAR scores of 7 and 9 at the 5th and 10th minutes, respectively.

Importantly, the mother was diagnosed with uncomplicated P. falciparum malaria with mixed infection one week before delivery and was treated with a full course of artemether-lumefantrine 20/120 mg, 4 tablets twice daily for three days. At the time of the neonate’s diagnosis, the mother was asymptomatic and tested negative for malaria by both rapid diagnostic test (RDT) and microscopy.

The neonate was initially diagnosed with early-onset neonatal sepsis owing to respiratory distress and subsequently received intravenous antibiotics, namely, ampicillin 50 mg/kg BID and 4 mg/kg of intravenous gentamicin daily. Despite initial treatment for neonatal sepsis, the neonate’s fever persisted without a clear periodicity, prompting further investigation. The neonate presented with vital signs indicating a pulse rate (PR) of 157 beats/minute, a respiratory rate (RR) of 68 breaths/minute, a temperature of 38.5 °C, and an oxygen saturation of 92%. He weighed 3500 g and exhibited pink conjunctivae. Upon examination, there was no splenomegaly, and he had a normal lymphatic system, respiratory system, cardiovascular system, and genitalia. Neurological examination revealed intact neonatal reflexes.

After 24 hours of admission, laboratory investigations revealed a hemoglobin level of 14.7 mg/dl (normal range: 12–20 mg/dl), a white blood cell (WBC) count of 9.9 × 109/L (normal range: 9.0 to 16.0 × 109/L), and a platelet count of 182 × 109/L (normal range: 150 to 400 × 109/L). Blood group analysis indicated blood group A + , and blood film microscopy revealed coinfection with P. falciparum and P. vivax parasites.

Radiological findings from X-ray imaging revealed clear lung fields, normal-sized and dense hila, sharp costophrenic angles, a normal cardiothoracic ratio, normal pulmonary vascularity, and a visibly normal thoracic cage structure. The conclusion drawn from the radiological assessment was one of normal findings.

The combined findings of persistent fever, positive blood film for malaria parasites, a negative workup for bacterial infection, and normal radiological findings led to the diagnosis of congenital malaria with coinfection of P. falciparum and P. vivax parasites, and the initial suspicion of neonatal sepsis was ruled out.

Treatment and outcome

Based on the results of the malaria test, the neonate’s treatment regimen was switched to 3 mg/kg intravenous artesunate, which was administered at diagnosis and 12 h and 24 h later, following established protocols for neonatal malaria treatment. Following treatment initiation with artesunate, the patient’s fever subsided, and his clinical condition improved significantly within 24 h. The resolution of the fever and improved respiratory status indicated a positive response to treatment. After completing the three doses of intravenous antimalarial therapy, the neonate’s condition remained stable, and he was discharged from the hospital with a three-day course of fixed-dose combination oral artemisinin-lumefantrine (20/120 mg) pediatric flavored formulation, administered as one tablet twice daily (Table 1).

Table 1 Clinical timeline of symptoms, diagnostic interventions, and treatment for a neonate with congenital malaria in southern Ethiopia

Full size table

Discussion

This case report describes a neonate who was diagnosed with congenital malaria caused by coinfection with Plasmodium falciparum and Plasmodium vivax in Ethiopia.

As demonstrated in this case, a neonate born to a nonimmune mother in a malaria-endemic area can develop congenital malaria. This study also highlights the increased risk of transmission from nonimmune mothers in endemic areas [12]. On the other hand, mothers residing in endemic areas develop partial immunity through repeated exposure[13], which offers some protection to their newborns via placental and breast milk antibodies [14, 15]. Geographical variations in disease transmission dynamics further emphasize the importance of considering travel history [16].

The initial diagnosis in this patient was early-onset neonatal sepsis due to nonspecific symptoms such as fever and respiratory distress. This shows the challenge of differentiating congenital malaria from other neonatal infections with overlapping clinical presentations [[17](/article/10.1186/s13256-025-05525-3#ref-CR17 "Amimo FA, Amimo FA. Malaria Transmission Dynamics in East Africa. 2023. https://www.intechopen.com/online-first/88350

            .")\]. However, further investigation of persistent fever despite antibiotic therapy was initiated, leading to the diagnosis of congenital malaria. A detailed travel history, including the mother’s place of residence, and the use of diagnostic methods, such as blood film microscopy, are important for accurate diagnosis \[[13](/article/10.1186/s13256-025-05525-3#ref-CR13 "Harrington WE, Duffy PE. Congenital malaria: rare but potentially fatal. Ped Health. 2008;2(2):235."), [18](/article/10.1186/s13256-025-05525-3#ref-CR18 "Svenson JE, MaClean JD, Gyorkos TW, Keystone J. Imported malaria: clinical presentation and examination of symptomatic travelers. Arch Intern Med. 1995;155(8):861–8.")\].

The initiation of appropriate antimalarial therapy according to established protocols resulted in a positive clinical outcome, with fever subsiding and respiratory distress improving within 24 hours. Similar studies emphasize the importance of early recognition and prompt treatment to prevent progression to severe disease and adverse outcomes [19, 20].

The mother in this case received ANC services elsewhere, suggesting potential gaps in communication or education regarding malaria risks upon travel to endemic regions. However, studies suggest the importance of comprehensive services that address travel history and potential malaria exposure, in addition to maternal obstetric management [21, 22]. Additionally, intermittent preventive treatment (IPTp) with antimalarial drugs during pregnancy is effective in reducing the risk of malaria [23, 24].

Conclusion

This case report highlights the importance of considering congenital malaria as a differential diagnosis for febrile neonates, especially those with a history of travel or delivery in endemic areas. A detailed travel history combined with clinical evaluation and blood film microscopy is crucial for diagnosis. Prompt initiation of appropriate antimalarial therapy on the basis of a confirmed diagnosis is essential for achieving optimal clinical outcomes. Furthermore, implementing effective preventive measures through strengthened antenatal care services, including intermittent preventive treatment (IPTp), can significantly reduce the burden of congenital malaria.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

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Acknowledgements

We acknowledge the dedicated staff of the Neonatal Intensive Care Unit at Dil-Fana Hospital, Arba Minch, Ethiopia, for their exceptional care and the information they provided for this report. We also express our gratitude to the mother of the neonate for her consent and cooperation.

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Authors and Affiliations

  1. College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
    Biniyam Demisse Andarge
  2. Department of Pediatrics, Dil-Fana Hospital, Arba Minch, Ethiopia
    Kebede Almaw

Authors

  1. Biniyam Demisse Andarge
  2. Kebede Almaw

Contributions

The authors confirm the following contributions: KA conceived and designed the study; BD acquired and interpreted the data and drafted the manuscript. Both authors approved the final version and agreed to be accountable for their respective contributions, ensuring any questions regarding the work are appropriately addressed.

Corresponding author

Correspondence toBiniyam Demisse Andarge.

Ethics declarations

This study was conducted following ethical principles, and ethical approval for this case report was obtained from the institutional review board (IRB) of Arba Minch University.

Written informed consent was obtained from the patient’s legal guardian for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

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The authors declare that they have no competing interests.

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Andarge, B.D., Almaw, K. Congenital malaria in a neonate born in a malaria-endemic area: a case report.J Med Case Reports 19, 434 (2025). https://doi.org/10.1186/s13256-025-05525-3

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