Congenital infection with Plasmodium malariae: a rare case of intrauterine transmission in Germany.

Background: Malaria remains the leading parasitic disease worldwide with a significant global morbidity and mortality burden. Plasmodium malariae, the least prevalent of the five Plasmodium species that cause human malaria, has unique characteristics including prolonged prepatent periods and life-long persistance. In non-endemic countries and particular in neonates with coexisting diseases diagnosis and therapy pose challenges.

Case presentation: We report a rare case of severe congenital P. malariae malaria in a 2-month-old female infant born in Germany to a Nigerian mother. The infant presented with fever, hepatosplenomegaly, jaundice, and respiratory distress. Initial workup revealed significant haemolysis, hepatopathy, and thrombocytopenia. Microscopic and PCR confirmed P. malariae. Shortly after the initial presentation, the infant developed clinical signs of cerebral malaria and organ failure, requiring invasive ventilation, anti-seizure medication, and vasoactive support. Following treatment with intravenous artesunate and oral atovaquone/proguanil, the infant showed significant improvement and was discharged after 36 days (22 days of paediatric intensive care) with a multidisciplinary follow-up plan. At six months post-discharge, she demonstrated stable organ function and mild developmental delay.

Conclusion: The case highlights the diagnostic and therapeutic complexities of life-threatening congenital P. malariae infections in non-endemic countries. It underlines the importance of clinicians' awareness of maternal travel or migration history and individualized treatment strategies. The increasing global mobility necessitates updated guidelines for congenital malaria management even for less likely P. malariae infections. Prophylactic measures, early recognition, and multidisciplinary management are critical for improving outcomes for such rare but severe presentations and their long-lasting complications. Possible comprehensive neonatal malaria screening in high-risk populations should be considered in the future.