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Case Reports
Patient 1
Patient 1 was a 29-year-old woman who presented to her physician on September 9, 1991, with a four-day history of fevers (temperature, up to 39.9 °C [103.8 °F]), chills, headache, and a petechial rash on her legs. A blood smear, obtained four days earlier as part of a workup for hemochromatosis and just hours before the fevers started, demonstrated intraerythrocytic parasites consistent with malaria (Figure 1A). The patient had never traveled outside the United States, and in the previous year she had not left southern New Jersey. She had not received any blood transfusions, used intravenous drugs, or been exposed to hypodermic needles. Because she had not traveled to an area of endemic malaria, a diagnosis of babesiosis was made and a therapeutic course of quinine and clindamycin was started. The blood smears were sent to the Division of Parasitic Diseases of the Centers for Disease Control and Prevention (CDC) in Atlanta for review, where a diagnosis of P. vivax infection was made. Primaquine was added to the patient's therapy, and clindamycin was discontinued.
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Patient 2 was an eight-year-old boy who was brought to his pediatrician on September 16, 1991, with a two-day history of fevers (temperature, up to 40.3 °C [104.5 °F]). An initial diagnosis of otitis media was made, and the boy was given amoxicillin. The fevers persisted, and the therapy was changed to cefaclor on September 18. The boy was hospitalized on September 20 with persistent fevers. The hematocrit was 35.2 percent, the red-cell count was 4.4 million per cubic millimeter, and the white-cell count was 3.6 per cubic millimeter, with 62 percent neutrophils, 5 percent band forms, and 25 percent lymphocytes. His platelet count was 111,000 per cubic millimeter. Because of the anemia, leukopenia, and thrombocytopenia, a bone marrow biopsy was performed on September 21 to rule out a diagnosis of leukemia. P. vivax parasites were identified in the biopsy specimen and the peripheral-blood smear (Figure 1B). Blood smears were sent to the CDC, and the diagnosis of malaria was confirmed. The patient's therapy was changed to chloroquine and primaquine, and the fevers resolved.
Both patients were asymptomatic at a two-year follow-up visit.
Epidemiology
Patient 1 lives in Sicklerville, New Jersey, a flat, low-lying agricultural area of Camden County that is becoming suburbanized, with widely scattered housing developments. The area has many freshwater ponds, drainage basins, and brushy areas with standing water. The patient's home is an apartment at the end of a single-story apartment complex approximately 15 m (50 ft) from a small pond. On many evenings in the summer of 1991 she sat on her patio, and she recalls being bitten frequently by mosquitoes.
Patient 2 lives in Manalapan, New Jersey, a flat, formerly agricultural area in Monmouth County that has become rapidly suburbanized in the past 10 years. Drainage ditches, standing water, and wet areas are common. In the summer of 1991 the patient participated in numerous outdoor activities; however, he was always home by dusk. The only travel reported was a two-week trip to Florida in early July. He had not traveled to southern New Jersey, where Patient 1 lives, nor had he ever traveled outside the United States.
Mosquito-collection surveys, routinely performed by local mosquito-control commissions in New Jersey, estimate the population of various mosquito species. Surveys in the Sicklerville area indicated that the seasonal rise in Anopheles quadrimaculatus populations began two months earlier than usual in 1991, producing five to six times more mosquitoes than in 1990 in the months of May, June, and July. There were no traps in the Manalapan area, but others in Monmouth County indicated that A. quadrimaculatus counts remained low.
Discussion
An average of 60 cases of malaria are reported to the New Jersey Department of Health each year (range from 1987 to 1991, 40 to 76) (unpublished data). Except for the two cases described here, there has been no evidence of malaria transmission in New Jersey in the past 30 years. All other reported cases of malaria have been associated with recent travel to, or immigration from, areas of endemic malaria elsewhere in the world (unpublished data).
Confirmed transmission of malaria has been documented in the United States within the past 10 years1,2,3. In each episode, the source of the infection was traced to unregistered farm workers from Mexico, who had generally been living under poor conditions in rural areas, facilitating their exposure to anopheline vectors. The two cases in New Jersey are distinctive because they occurred in areas that were more developed and more suburban. The source of malaria in these two cases could not be identified. A. quadrimaculatus, which is native to the eastern and central United States north to southern Canada, is fully capable of transmitting malaria from a person with gametocytemia.
In the Mexican workers with gametocytemia, limited access to health care services while in the United States was cited as a possible reason P. vivax infection was undiagnosed and untreated. New Jersey has a growing number of unskilled laborers, many of whom work in industries with no employer-provided health care benefits. Our investigation identified an unskilled laborer, a recent immigrant from Honduras living less than a mile from Patient 1, who waited four weeks before seeking treatment for P. vivax infection in May 1991, illustrating the potential for malaria infections to go untreated.
New Jersey also has a growing resident population of immigrants from countries in Southeast Asia, the Indian subcontinent, West Africa, and Central America where malaria is endemic. Census data for 1980 and 1990 show that the population of Indians grew by 230 percent in Monmouth County and by 74 percent in Camden County. Similar data for other immigrant groups are not available. In comparison, the total population of Monmouth County grew by only 10 percent and that of Camden County by 7 percent during the same period4,5.
The report of the Institute of Medicine on emerging infections warns of the potential for malaria to become reestablished in the United States6. The two apparently unlinked cases of P. vivax infection reported here illustrate how malaria transmission could be reintroduced into the United States. Surveillance systems capable of detecting the reemergence of infectious diseases must be maintained in order to detect new disease trends early enough to make simple control measures effective.
We are indebted to Julianne Wilkin, D.O., University of Medicine and Dentistry of New Jersey, Stratford, and Wondwessen Bekele, M.D., Newark Beth Israel Hospital, Newark, for reporting these cases, and to the mosquito-control commissions of Camden County and Monmouth County for providing data on mosquito surveillance.
Source Information
From the Division of Epidemiology, Environmental and Occupational Health Services, New Jersey Department of Health, Trenton (J.H.B., C.A.G., K.C.S.); and the Malaria Branch, Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta (P.B.B., J.R.Z.).
Address reprint requests to Dr. Brook at the New Jersey Department of Health, CN-369, Trenton, NJ 08625-0369.
References
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Related Letters:
Malaria in New Jersey
Gill G., Dabrow M. B., Brook J. H., Bloland P. B., Zucker J. R.
Extract |
Full Text
N Engl J Med 1994;
331:1454-1455, Nov 24, 1994.
Correspondence
This article has been cited by other articles:
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