Higher Rates of Misdiagnosis in Pediatric Patients Versus Adults Hospitalized With Imported Malaria

Abstract

Objectives Despite the availability of effective anti-malarial prophylaxis, imported adult and pediatric malaria occurs in the United States and this can pose diagnostic issues. We examined the clinical characteristics and diagnostic challenges of imported malaria requiring adult or pediatric inpatient admission at Montefiore Medical Center (MMC) in the Bronx which provides care for a large population of immigrants from malaria endemic areas. Study Design We conducted a retrospective single center review of patients admitted with a diagnosis of malaria at MMC from 2005 through 2012. We extracted historical, clinical, and laboratory values from the electronic medical record and patient charts. Results We identified 95 patients who were diagnosed and hospitalized with malaria from 2005–2012, 33 (35%) of them children and 17 (18%) with severe malaria. Most patients contracted malaria while visiting friends and relatives (VFR) in West Africa. Only 38% of travelers took prophylaxis, and fewer than half reported taking it as prescribed. Misdiagnosis by emergency room or primary care doctors was observed in almost one quarter of all of the patients. Misdiagnosis occurred significantly more frequently in children (43%) compared to adults (13%) (p=0.002). Pediatric patients were more likely to present with abdominal pain (42% vs 15%, p=0.005). Conclusions Pediatric patients admitted for imported malaria at MMC had a higher rate of misdiagnosis and presented with more gastrointestinal symptoms than hospitalized adults. By describing the clinical characteristics of patients with imported malaria, we hope to improve diagnostic accuracy by healthcare workers and raise awareness that VFRs may require more intensive pre-travel counseling.

Severity of Plasmodium falciparum and Non-falciparum Malaria in Travelers and Migrants: A Nationwide Observational Study Over 2 Decades in Sweden

“…Delayed diagnosis and antimalarial treatment are well-known risk factors for severe malaria and death [8, 10]. Our analysis showed that diagnosis was delayed at least 1 day after health care presentation in nearly one-fifth of all malaria episodes, as previously observed in other nonendemic settings [29]. For P. falciparum, health care delay was associated with severe malaria, criteria prognostic of unfavorable outcome, and ICU admission.…”

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“…Adults with SFM have a generalised increase in vascular permeability [13], and so fluid loading may lead to complications and pulmonary oedema. Fluid boluses significantly increased 48-h mortality in critically ill children with impaired perfusion [14]. Thus, to correct hypovolaemia in patients with severe malaria, the consensus upholds the old malariologist's adage to “run them dry” [1].…”

Recurrent Fever in Children

“…Due to its severity, malaria should be promptly ruled out in febrile patients who have recently traveled in endemic areas. Because paroxysms are less evident in children, who additionally present with more gastrointestinal symptoms compared with adults, the risk of misdiagnosis is high in the pediatric age group [ 83 ].…”