This prompted an investigation to look for a nosocomial route of transmission. No locally acquired cases of malaria had been reported in the regional area. She had no history of recent travel to any areas that are endemic for malaria. The patient lives with her parents in the Baltimore-Washington area ≈12 miles from the nearest international airport. Initial and follow up tests on patient 2 were negative for viral bloodborne pathogens.
After 3 blood transfusions and quinidine gluconate and doxycycline therapy, the patient was discharged on hospital day 14, with a stable hematocrit, persistent gametocytemia, and splenomegaly. falciparum malaria, with 12% parasitemia and ≈200 gametocytes/mm 3. Formal review of her peripheral blood smear by the hematology consultation service showed intraerythrocytic ring forms indicative of P. Despite administration of antimicrobial drugs for presumed microbial sepsis, the following conditions developed over the next 72 hours: persistent spiking fevers loose, nonbloody stools splenomegaly abdominal distension and bilateral lower extremity edema. The leukocyte count was 1,890 cells/mm 3, hematocrit was 35.2%, platelets were 47,000/mm 3, and total bilirubin was 1.5 mg/dL. Patient 2 was febrile and pale, with no notable change in her baseline neurologic state. Persistent fever and pancytopenia developed and resulted in her readmission to unit A of the tertitary care hospital, now 23 days after sharing the room with patient 1. A week after discharge and 17 days after sharing the semiprivate room, patient 2 was admitted to another hospital (3-day stay), and a viral illness was diagnosed after all cultures were negative for pathogens. Medicine doses given and blood samples drawn were documented with a separation time >50 minutes. Chart review and interviews indicated that neither patient had glucose monitoring by glucometer, blood transfusions, common infusions such as contrast material, or a needlestick injury report, all events that have been previously implicated in nosocomial malaria. Patient 1 received a continuous quinidine gluconate infusion through a peripheral intravenous line. Patients 1 and 2 shared a unit A semiprivate room for ≈24 hours. Seven days before patient 1's admission, patient 2, a 14-year-old girl, with severe developmental delay, was admitted to unit A for placement of a surgical feeding tube. falciparum malaria with 4% parasitemia and transfer to unit A of a tertiary care hospital, he responded well to antimalarial therapy and was discharged 2 days later. Abdominal pain, emesis, and a high fever developed in patient 1, a 9-year-old Gambian boy with sickle cell disease residing in the United States, during the flight home after a month in the Gambia he had taken no malaria prophylaxis drugs.
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