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in 2010 , there were roughly 219 million cases of malaria reported worldwide resulting in an estimated 660,600 deaths .
in contrast , the total number of cases according to the centers for disease control and prevention ( cdc ) in the united states ( usa ) was only 1691 .
here , we describe a case of imported malaria and conduct a retrospective case series at four connecticut ( ct ) hospitals in order to describe the demographics of imported malaria and to identify potential barriers to timely diagnosis and treatment .
a 24-year - old african - american female college student with no significant past medical history presented to the emergency room with fever , lower abdominal pain and nausea without vomiting starting the day prior to admission .
she noted that her menstrual period was slightly late , but otherwise the history obtained was non - contributory . in the ed , she was found to be febrile ( 102 f ) and tachycardic .
as a result , a pelvic examination was performed , which was unremarkable aside from scant blood in the vaginal canal and a closed cervix .
ultrasound of the abdomen and pelvis demonstrated a fetal sac in the uterus , but was otherwise within normal limits .
routine diagnostic testing was notable for a normal white blood count , normal hemoglobin , low platelets ( 92,000 ) , normal kidney function ( cr 0.6 ) , mild transaminitis ( alt 84 , ast 72 ) and an indirect hyperbilirubinemia ( tb 1.4 , db 0.3 ) .
urinalysis demonstrated 56 wbcs , 910 rbcs , 1012 epithelial cells , 1 + bacteria and trace leukocytes .
she was subsequently admitted to the medical service with the diagnosis of uti and threatened abortion and was started on nitrofurantoin and iv fluids .
morning laboratory investigations revealed a new leukopenia ( wbc 2.8 ) and worsening thrombocytopenia ( plt 66,000 ) . as a result ,
given her worsening septic picture , infectious disease was consulted , a peripheral blood smear sent and doxycycline started for concern of ehrlichiosis . during the infectious disease evaluation , it is discovered that both the patient and her husband had recently traveled to nigeria , her husband had been infected with malaria during their visit there , and she herself had developed a fever a day prior to returning to the usa and had become so ill en route that she presented to the emergency room directly from the airport .
subsequently , the peripheral smear was reviewed by the i d attending in the laboratory and intracellular 
as a result , the patient was diagnosed with uncomplicated malaria given no evidence of complications meeting criteria for severe malaria ( namely , severe anemia , renal failure , ards , and hyperparasitemia ) .
however , the decision was made to treat immediately with atovaquone / proguanil given that it was more readily available from an outside pharmacy than waiting for artemisinin - based medication sent directly from the cdc .
it was not until the third day of hospitalization that she received appropriate treatment . with anti - malarials ,
her clinical condition improved and she defervesced over the next 48  h. she was eventually discharged home after a six - day admission .
we conducted a retrospective case series of all patients with confirmed diagnosis of malaria from 2001 to 2012 at four connecticut teaching hospitals ( waterbury hospital , st .
raphael , & griffin hospital ) in order to describe the demographics of imported malaria and to identify potential barriers to timely diagnosis and treatment . of a total of the fourteen patients ,
most patients were foreign residents visiting the usa ( 54% ) , while the rest were usa citizens .
a vast majority of patients were traveling in sub - saharan africa ( 73% , 9% india , 9% pakistan , 9% dominican republic ) .
symptoms began on average 3.1 days ( range 18 , sd 2.8 ) after arrival to the usa and patients presented to a healthcare provider on average 4.7 days ( range 037 , sd 12.1 ) after onset of symptoms . at the time of presentation , malaria was on the differential diagnosis in only half of cases and travel history was documented in only 69% of cases . mean time to diagnosis was 2.9 days ( range 012 , sd 3.6 ) .
the vast majority of cases were due to p. falciparum ( 92% ) , while the remaining case was due to plasmodium vivax .
appropriate treatment was initiated in 93% of cases and mean time to treatment from time of presentation was 3.0 days ( range 012 , sd 3.6 ) .
anti - malarial medications were available in the hospital pharmacy for only half of the cases .
for these patients , treatment was administered promptly ( mean 2.2  h , range 13  h ) . in cases
where medications were not available in the hospital , there was a significant time delay between when the drug was ordered and when it was administered with 75% of patients receiving treatment 8  h ( mean 10.3  h , range 712  h ) after it was ordered . in general , patients responded well to treatment .
patients requiring inpatient admission were hospitalized on average for 3.2 days ( range 17 , sd 1.9 ) .
internationally , malaria is a life - threatening infectious disease resulting in as many as 500 million estimated cases annually .
in contrast , domestically , malaria is no longer endemic and instead is imported via international travel and immigration from afflicted parts of the world . according to department of homeland security ,
about 12,000 people obtained legal residence in connecticut during 2011 . in comparison , the bordering state of new york had close to 150,000 legal immigrants out of a total of just over 1 million for the us as a whole . with regards to malaria ,
connecticut had a total of 21 reported cases compared to the 1691 nationwide in 2010 .
the incidence of malaria in connecticut is comparable to that of the us ( 0.6 vs. 0.5 cases of malaria per 100,000 people , respectively ) , , . given the rise of globalization , the number of cases of malaria has increased proportionally in the us . according to the cdc ,
the number of cases of malaria in 2010 was a 30% increase compared to 2008 and a 14% increase compared to 2009 .
similarly , the united kingdom reported a 29% increase of malaria cases from 2008 to 2010 .
several possible factors have been identified for the delay in diagnosis and treatment of imported malaria . in 2000 , dorsey et al . reviewed 121 confirmed cases of malaria over a 10-year period in san francisco , california and found that in 19 ( 16% ) of these cases the initial physician missed the diagnosis of malaria .
similarly , our analysis determined that in 31% of imported malaria cases a travel history was not documented and in half of the cases malaria was not considered on the differential diagnosis . in 1998 , kain et al . performed a prospective analysis of the diagnosis and treatment of malaria in toronto , canada . in that study ,
the correct initial diagnosis was not made in 59% of cases and there was a delay in treatment for cases of p. falciparum by about 7 days .
in our series , the mean time to treatment was also delayed until approximately 3 days after presentation to a healthcare provider .
furthermore , these treatment delays were often exacerbated by the unavailability of anti - malarials in hospital pharmacies .
lastly , the cdc has long recommended chemoprophylaxis against malaria . however , only a minority of travelers is compliant with prophylactic medications , , .
similarly , in our results , only about one - fifth of the patients took anti - malarial prophylaxis . in conclusion ,
imported malaria is relatively uncommon in the us , but each year the number of cases continues to rise given trends in globalization and international travel .
however , when these cases presented to the healthcare system , malaria was not entertained on the differential diagnosis , travel history was not obtained , chemoprophylaxis was underutilized , and anti - malarials were not available in hospital pharmacies in substantial proportion of these cases resulting in possible delays in diagnosis and treatment . based on these findings , we wish to re - emphasize and recommend that:1.all individuals traveling to malaria endemic parts of the world be evaluated by a travel clinic prior to departure and to stress the importance of anti - malarial prophylaxis;2.all healthcare providers must maintain a broad differential diagnosis and take a thorough travel history given that imported tropical diseases will become more commonplace in the setting of globalization in order to prevent delays in diagnosis;3.all healthcare provides should be familiar with trends in global health in order to be informed of the growing mobility and the evolving epidemiology of infectious diseases;4.all hospital pharmacies should have anti - malarial medications stocked to allow for prompt treatment of this life - threatening infectious disease .
all individuals traveling to malaria endemic parts of the world be evaluated by a travel clinic prior to departure and to stress the importance of anti - malarial prophylaxis ; all healthcare providers must maintain a broad differential diagnosis and take a thorough travel history given that imported tropical diseases will become more commonplace in the setting of globalization in order to prevent delays in diagnosis ; all healthcare provides should be familiar with trends in global health in order to be informed of the growing mobility and the evolving epidemiology of infectious diseases ; all hospital pharmacies should have anti - malarial medications stocked to allow for prompt treatment of this life - threatening infectious disease .
in 2010 , there were roughly 219 million cases of malaria reported worldwide resulting in an estimated 660,600 deaths [ 1 ] . 
 in contrast , the total number of cases according to the centers for disease control and prevention ( cdc ) in the united states ( usa ) was only 1691 [ 2 ] . 
 of those , 1688 were cases of imported malaria [ 2 ] . 
 this is the highest number of cases reported in u.s . since 1980 
 [ 2 ] . here 
 , we describe a case of imported malaria and conduct a retrospective case series at four connecticut ( ct ) hospitals in order to describe the demographics of imported malaria and to identify potential barriers to timely diagnosis and treatment .