We report a case of acute Plasmodium malariae infection complicating corticosteroid treatment for membranoproliferative glomerulonephritis in a patient from an area where P. malariae infection is not endemic. A peripheral blood smear showed typical band-form trophozoites compatible with P. malariae or Plasmodium knowlesi. SSU rRNA sequencing confirmed the identity to be P. malariae.
CASE REPORTA 72-year-old man with membranoproliferative glomerulonephritis, hypertension, and ␣-thalassemia trait was admitted to our hospital because of chills and rigor for 2 days and a fever on the day of admission. He had been diagnosed with membranoproliferative glomerulonephritis 3 years prior to admission, when he presented with nephrotic syndrome. Autoimmune marker testing showed a raised level of antinuclear antibody (Ͼ1/720), with a normal level of anti-double-stranded-DNA antibody (Ͻ5 IU/ml) and a negative result for antineutrophil cytoplasmic antibody (ANCA). Testing for hepatitis B virus surface antigen showed a negative result. His initial renal biopsy specimen at diagnosis showed immune deposits of IgA, IgG, IgM, C3, and C1q. He was treated with high-dose corticosteroid with partial response. Two months prior to admission, he had recurrent lower limb edema and was confirmed to have a relapse of the nephrotic syndrome, with urine protein excretion of 2.78 g/day. Prednisolone at 50 mg once daily was started 50 days before admission, with a gradual tailing dose. On the day of admission, his prednisolone dosage was 35 mg once daily. The patient was a resident of Hong Kong. He occasionally traveled to southern China, but he has never traveled outside this area in his lifetime. He has never received a blood transfusion.On admission, he had a temperature of 39.3°C and a heart rate of 138 beats per minute. His blood pressure was 144/68 mm Hg. Physical examination revealed bilateral lower limb edema. The spleen was not palpable. A blood test showed thrombocytopenia with a platelet count of 69 ϫ 10 9 /liter. The platelet count 6 weeks before admission was within the normal range (253 ϫ 10 9 /liter). The total white cell count was 4.4 ϫ 10 9 /liter, with a neutrophil count of 4.09 ϫ 10 9 /liter and a lymphocyte count of 0.26 ϫ 10 9 /liter. The hemoglobin level was 7.4 g/dl. Biochemical tests revealed a creatinine level of 2.68 mg/dl and an albumin level of 31 g/liter. The levels for bilirubin and liver parenchymal enzymes were within the normal range. A peripheral blood smear showed normalsized erythrocytes, thick rings (Fig. 1a), band-form trophozoites (Fig. 1b), and schizonts containing dark brown pigments (Fig. 1c), compatible with Plasmodium malariae or P. knowlesi.