Intended for healthcare professionals

Practice Easily Missed?

Imported malaria

BMJ 2013; 346 doi: (Published 30 May 2013) Cite this as: BMJ 2013;346:f3214
  1. Merlin L Willcox, general practitioner1,
  2. Jill Mant, paediatric specialist registrar2,
  3. Tim O’Dempsey, consultant in tropical medicine3
  1. 1Department of Primary Care Health Sciences, University of Oxford, Oxford OX1 2EP, UK
  2. 2Department of Paediatrics, Luton Hospital, Luton, UK
  3. 3Liverpool School of Tropical Medicine, Liverpool, UK
  1. Correspondence to: M L Willcox merlin.willcox{at}
  • Accepted 3 May 2013

A 19 year old student phoned an official health service telephone helpline with a 10 day history of aching legs, vomiting, diarrhoea, and abdominal pain. She mentioned a recent trip to Uganda but was reassured and told she had “flu.” The next day her boyfriend took her to see her doctor, where she mentioned general malaise, tiredness, and occasional nausea; the doctor diagnosed a viral illness and advised her to keep taking paracetamol. Three days later a friend found her dead in bed in her university halls of residence. The coroner recorded death due to cerebral malaria.1

What is malaria?

Malaria is an infection caused by protozoa of the genus Plasmodium. Five species infect humans (P falciparum, P vivax, P ovale, P malariae, and P knowlesi). Most of the fatal cases are caused by P falciparum.

How common is malaria?

  • Worldwide over 200 million cases of malaria occur annually and 0.5-1 million deaths, 90% of which are among children in Africa2

  • Plasmodium falciparum accounted for about 70% of the 1677 cases notified in the United Kingdom in 2011, whereas 25% of cases were due to P vivax3

  • Of the 191 deaths from malaria in the United Kingdom from 1987 to 2006, 184 were due to P falciparum4

  • About 20% of imported malaria cases are in children5

Why is malaria missed in non-endemic countries?

As illustrated by the case described here, the symptoms of malaria are non-specific and can easily be mistaken for a viral illness such as influenza, unless clinicians think to ask patients whether they have travelled abroad.

A retrospective observational study of 191 deaths due to malaria in the United Kingdom from 1987 to 2006 found that the case fatality was inversely related to incidence, suggesting that cases were more easily missed by clinicians unaccustomed to seeing this disease.4 A retrospective series of 39 …

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