CASE PRESENTATION: An army officer who returned from Malaysia in October 2016 was found to be positive for Plasmodium both by microscopy and rapid diagnostic test (RDT) by the Anti Malaria Campaign Sri Lanka (AMC) during his third visit to a health care provider. Microscopy findings were suspicious of P. knowlesi infection as the smears showed parasite stages similar to both Plasmodium malariae and Plasmodium falciparum. Nested PCR at AMC confirmed Plasmodium genus, but not the species. In the absence of species confirmation, the patient was treated as a case of P. falciparum. The presence of P. knowlesi was later confirmed by a semi-nested PCR assay performed at the Environmental Health Institute, National Environmental Agency in Singapore. The parasite strain was also characterized by sequencing the circumsporozoite gene. Extensive case investigation including parasitological and entomological surveillance was carried out.
CONCLUSIONS: Plasmodium knowlesi should be suspected in patients returning from countries in the South Asian region where the parasite is prevalent and when blood smear results are inconclusive.
METHODS: Two Malaysians went to Nigeria for two weeks. After returning to Malaysia, they fell sick and were admitted to different hospitals. Plasmodium ovale parasites were identified from blood smears of these patients. The species identification was further confirmed with nested PCR. One of them was successfully treated with no incident of relapse within 12-month medical follow-up. The other patient came down with malaria-induced respiratory complication during the course of treatment. Although parasites were cleared off the circulation, the patient's condition worsened. He succumbed to multiple complications including acute respiratory distress syndrome and acute renal failure.
RESULTS: Sequencing of the malaria parasite DNA from both cases, followed by multiple sequence alignment and phylogenetic tree construction suggested that the causative agent for both malaria cases was P. ovale curtisi.
DISCUSSION: In this report, the differences between both cases were discussed, and the potential capability of P. ovale in causing severe complications and death as seen in this case report was highlighted.
CONCLUSION: Plasmodium ovale is potentially capable of causing severe complications, if not death. Complete travel and clinical history of malaria patient are vital for successful diagnoses and treatment. Monitoring of respiratory and renal function of malaria patients, regardless of the species of malaria parasites involved is crucial during the course of hospital admission.
CASE REPORT: A 54-year-old male patient was hospitalized after a trip to Malaysia with strong greenish watery diarrhea and chills. On physical examination we saw a dehydrated patient in severely reduced general condition. The stool frequency was 30/d. The laboratory examinations only showed elevated parameters of inflammation. Plesiomonas shigelloides was cultivated in the stool cultures. With appropriate substitution of fluid and electrolytes, and antidiarrheal therapy the patient resumed a normal diet without any complications. Three days later his bowel movements were normal and his general condition was greatly improved. We withheld antibiotic therapy because of the noncomplicated course of illness.
CONCLUSION: In Germany infections with Plesiomonas shigelloides are rare, an increase is observed because of increasing tourism to tropical regions. The course of infection is sometimes asymptomatic, but usually patients develop an acute gastroenteritis. Especially immunocompromised patients can show serious courses of infection. Plesiomonas shigelloides should be included in the differential diagnosis of acute gastroenteritis after journeys to tropical regions. Some of our patients, however, denied traveling to tropical regions. They also denied consuming seafood, which indicates a risk of infection in Germany. Still an infection with Plesiomonas shigelloides seems to be rare in northern European countries.
MATERIALS & METHODS: Data for subdistricts in Malaysia and radiotherapy services were extracted from Department of Statistics Malaysia and Directory of Radiotherapy Centres (DIRAC). Data from DIRAC were validated by direct communication with centres. Locations of radiotherapy centres, distance and travel time to the nearest radiotherapy were estimated using web mapping service, Google Map.
RESULTS: The average distance and travel time from Malaysian population to the closest radiotherapy centre were 82.5km and 83.4mins, respectively. The average distance and travel were not homogenous; East Malaysia (228.1km, 236.1mins), Central (14.4km, 20.1mins), East Coast (124.2km, 108.8mins), Northern (42.9km, 42.8mins) and Southern (36.0km, 39.8mins). The MV/million population for the country is 2.47, East Malaysia (1.76), Central (4.19), East Coast (0.54), Northern (2.40), Southern (2.36). About 25% of the population needs to travel >100 km to get to the closest radiotherapy facility.
CONCLUSION: On average, Malaysians need to travel far and long to reach radiotherapy facilities. The accessibility to radiotherapy facilities is not equitable. The disparity may be reduced by adding centres in East Malaysia and the East Coast.