Plasmodium malariae - B

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Record number: 
Adverse Occurrence type: 
MPHO Type: 
Time to detection: 
9 weeks
Alerting signals, symptoms, evidence of occurrence: 
59 year old Dutch woman presented with spiking fevers, headache, nausea, night sweats of 4 days duration following transfusion of RBC 9 weeks earlier, when she had had a coronary bypass surgery. She had never been abroad nor close to an airport so a presumptive diagnosis of TTI was made. The Dutch born donor had donated whole blood 15 times over 5 yeas; he had travelled to malaria endemic countries on 3 occasions and had been deferred for 6 months following trips to Africa and Costa Rica. Thin and thick blood smears were initially negative, and PCR detected very low copy number of P. malariae DNA in blood (1-100 parasites/ml); weak antibody positivity was also detected by immunofluorescence. Isolated thrombocytopaenia of 126x10-9/L had been noted for the past 5 years. Donor was treated with Chloroquine, the infection cleared and the platelet levels normalised.
Demonstration of imputability or root cause: 
Recipient did not have epidemiology to support exposure to malaria thorugh other routes. Donation archive tested positive for Plasmodium antibodies and subsequent sample tested positive by NAT, immunofluorescence and thick blood smear, all at low level. Low platelet levels in the donor normalised following treatment with Chloroquine.
Imputability grade: 
2 Probable
Suggest references: 
A case report of transfusion-transmitted Plasmodium malariae from an asymptomatic non-immune traveller. Brouwer EE et al. Malar J. 12:439, 2013.
Expert comments for publication: 
Transfusion-transmitted malaria infection in non-endemic countries is infrequent, due to strict donor selection guidelines. Such criteria varies from country to country, from different deferral parameters to serological and molecular-based testing; the optimal approach is a matter of local risk assessment in terms of epidemiology and operational resources. The highest risk in this context comes from donors who have resided in endemic areas and who may have asymptomatic, low level parasitemia; these donors can be identified by history and antibody testing. NAT can be used to further identify parasitemia and inform donor management in terms of treatment. These antibody positive, semi-immune donors may harbour variable, low level of parasites in blood and pose risk to blood safety. Of note, a commonly used EIA for the detection of Plasmodium antibodies failed to give a positive result, illustrating the difficulties in identifying these cases. Record 1744 contains another example and further relevant references.