- Case report
- Open Access
Severe Plasmodium ovale malaria complicated by acute respiratory distress syndrome in a young Caucasian man
© The Author(s) 2018
Received: 12 January 2018
Accepted: 23 March 2018
Published: 2 April 2018
Although Plasmodium ovale is considered the cause of only mild malaria, a case of severe malaria due to P. ovale with acute respiratory distress syndrome is reported.
A 37-year old Caucasian man returning home from Angola was admitted for ovale malaria to the National Institute for Infectious Diseases Lazzaro Spallanzani in Rome, Italy. Two days after initiation of oral chloroquine treatment, an acute respiratory distress syndrome was diagnosed through chest X-ray and chest CT scan with intravenous contrast. Intravenous artesunate and oral doxycycline were started and he made a full recovery.
Ovale malaria is usually considered a tropical infectious disease associated with low morbidity and mortality. However, severe disease and death have occasionally been reported. In this case clinical failure of oral chloroquine treatment with clinical progression towards acute respiratory distress syndrome is described.
Although Plasmodium ovale is considered the cause of only mild malaria, some reports indicate the potential evolution to severe disease and even death . A case of severe ovale malaria with acute respiratory distress syndrome (ARDS) unresponsive to previous therapy with chloroquine is reported.
Discussion and conclusion
Ovale malaria is usually considered a tropical infectious disease associated with low morbidity and mortality. However, severe disease and death have previously been reported .
In this case, clinical failure of oral chloroquine treatment in a patient with ovale malaria is described. Plasmodium ovale infection was confirmed by nested-PCR targeting the small sub-unit ribosomal RNA gene, detecting at least 10 parasite genomes per reaction and mixed infection with other Plasmodium spp were excluded . Persistent P. ovale parasitaemia during the first 48 h of oral chloroquine therapy was associated with clinical progression towards ARDS. Only 1 day after the switch to iv artesunate, the parasitaemia clearance was reached and the patient’s condition improved. Chloroquine is commonly used for the treatment of P. ovale infection. In non-falciparum malaria, resistance to chloroquine is reported only for Plasmodium malariae whereas P. ovale is usually considered fully chloroquine susceptible .
Moreover, in a systematic review to determine the efficacy and safety of artemisinin-based combined therapy (ACT) for the treatment of non-falciparum malaria, ACT was considered at least equivalent to chloroquine in effectively treating non-falciparum malaria .
Characteristics of previous cases of ARDS in Plasmodium ovale malaria
P. ovale subtype (wallikeri/curtisi)
Origin of infection
Time since exposition (days)
History of tuberculosis
Chloroquine phosphate + primaquine, quinine, artesunate
Chad ivory coast
DA, GTS and MI performed the clinical assessments, treated the patient and drafted the manuscript. SL, OA and CA performed the clinical assessments and treatment, searched the literature and drafted the manuscript. PMG performed molecular diagnostic tests and drafted the manuscript. DA and NE performed literature search, drafted and completed the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Availability of data and materials
Consent for publication
Written informed consent was obtained from the patient for publication of this case report.
Ethics approval and consent to participate
Institutional Review Board approval is not required by the Ethical Committee of the authors’ institution for the presentation of a single case report.
Publication of this report was supported by Ricerca Corrente and Ricerca finalizzata WFR PE-2013-02357936 funded by the Italian Ministry of Health.
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- Lau YL, Lee WC, Tan LH, Kamarulzaman A, Syed Omar SF, Fong MY, et al. Acute respiratory distress syndrome and acute renal failure from Plasmodium ovale infection with fatal outcome. Malar J. 2013;12:389.View ArticlePubMedPubMed CentralGoogle Scholar
- Snounou G, Viriyakosol S, Zhu XP, Jarra W, Pinheiro L, do Rosario VE, et al. High sensitivity of detection of human malaria parasites by the use of nested polymerase chain reaction. Mol Biochem Parasitol. 1993;61:315–20.View ArticlePubMedGoogle Scholar
- Oguike MC, Betson M, Burke M, Nolder D, Stothard JR, Kleinschmidt I, et al. Plasmodium ovale curtisi and Plasmodium ovale wallikeri circulate simultaneously in African communities. Int J Parasitol. 2011;41:677–83.View ArticlePubMedPubMed CentralGoogle Scholar
- WHO. Guidelines for the treatment of malaria. 3rd ed. Geneva: World Health Organization; 2015.Google Scholar
- Visser BJ, Wieten RW, Kroon D, Nagel IM, Bélard S, van Vugt M, et al. Efficacy and safety of artemisinin combination therapy (ACT) for non-falciparum malaria: a systematic review. Malar J. 2014;13:463.View ArticlePubMedPubMed CentralGoogle Scholar
- Taylor WR, Hanson J, Turner GD, White NJ, Dondrop AM. Respiratory manifestations of malaria. Chest. 2012;142:492–505.View ArticlePubMedGoogle Scholar
- Anstey NM, Handojo T, Pain MCF, Kenangalem E, Tjitra E, Prince RN, et al. Lung injury in vivax malaria: pathophysiological evidence for pulmonary vascular sequestration and posttreatment alveolar-capillary inflammation. J Infect Dis. 2007;195:589–96.View ArticlePubMedPubMed CentralGoogle Scholar
- Jang C-H, Choi J-H, Byun M-S, Jue D-M. Chloroquine inhibits production of TNF-alpha, IL-1beta and IL-6 from lipopolysaccharide-stimulated human monocytes/macrophages by different modes. Rheumatology (Oxf). 2006;45:703–10.View ArticleGoogle Scholar
- Groger M, Fischer HS, Veletzky L, Lalremruata A, Ramharter M. A systematic review of the clinical presentation, treatment and relapse characteristics of human Plasmodium ovale malaria. Malar J. 2017;16:112.View ArticlePubMedPubMed CentralGoogle Scholar
- Hachimi MA, Hatim EA, Moudden MK, Elkartouti A, Errami M, Louzi L, et al. The acute respiratory distress syndrome in malaria: is it always the prerogative of Plasmodium falciparum? Rev Pneumol Clin. 2013;69:283–6.View ArticlePubMedGoogle Scholar
- Lahlou H, Benjelloun S, Khalloufi A, Moudden EL, Hachimi MA, Errami M, et al. An exceptional observation of acute respiratory distress associated with Plasmodium ovale infection. Clin Chem Lab Med. 2012;50:A141.Google Scholar
- Rojo-Marcos G, Cuadros-González J, Mesa-Latorre JM, Culebras-López AM, de Pablo-Sánchez R. Acute respiratory distress syndrome in a case of Plasmodium ovale malaria. Am J Trop Med Hyg. 2008;79:391–3.PubMedGoogle Scholar
- Rozé B, Lambert Y, Gelin E, Geffroy F, Hutin P. Plasmodium ovale malaria severity (in French). Med Mal Infect. 2011;41:216–7.View ArticlePubMedGoogle Scholar