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Korean J Parasitol. Vol. 47, No. 3: 299-302, September 2009 DOI: 10.3347/kjp.2009.47.3.299
BRIEF COMMUNICATION
Imported Malaria in Korea: a 13-Year Experience in a
Single Center
Hae Suk Cheong1,�, Ki-Tae Kwon2,�, Ji-Young Rhee3, Seong Yeol Ryu4, Dong Sik Jung5, Sang Taek Heo6, Sang Yop Shin7, Doo Ryun Chung8, Kyong Ran Peck8,� and Jae-Hoon Song8,9 1Division of Infectious Diseases, Konkuk University Hospital, Konkuk University School of Medicine, Seoul 143-779, Korea; 2Division of Infectious Diseases, Daegu Fatima Hospital, Daegu 701-600, Korea; 3Division of Infectious Diseases, Dankook University Hospital, Dankook University School of Medicine, Cheonan 330-715, Korea; 4Division of Infectious Diseases, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu 700-712, Korea; 5Division of Infectious Diseases, Dong-A University Medical Center, Dong-A University School of Medicine, Busan 602-715, Korea; 6Division of Infectious Diseases, Gyeongsang Institute of Health Sciences, Gyeongsang National University Hospital, Jinju 660-702, Korea; 7Division of Infectious Diseases, Cheju National University Hospital, Cheju National University, Jeju 690-716, Korea; 8Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea; 9Asian-Pacific Research Foundation for Infectious Diseases (ARFID), Seoul 135-710, Korea Abstract: The incidence of imported malaria has been increasing in Korea. We reviewed data retrospectively to evaluate
the epidemiology, clinical features, and outcomes of imported malaria from 1995 to 2007 in a university hospital. All patients
diagnosed with imported malaria were included. Imported malaria was defined as a positive smear for malaria that was
acquired in a foreign country. A total of 49 patients (mean age, 35.7 year; M : F = 38 : 11) were enrolled. The predominant
malarial species was Plasmodium falciparum (73.5%), and the most frequent area of acquisition was Africa (55.1%), fol-
lowed by Southeast Asia (22.4%) and South Asia (18.4%). Fourteen-patients (30.6%) suffered from severe malaria caused
by P. falciparum and 1 patient (2.0%) died of multiorgan failure. Most of the patients were treated with mefloquine (79.2%)
or quinine (10.2%); other antimalarial agents had to be given in 13.2% treated with mefloquine and 44.4% with quinine
due to adverse drug events (ADEs). P. falciparum was the most common cause of imported malaria, with the majority of
cases acquired from Africa, and a significant number of patients had severe malaria. Alternative antimalarial agents with
lower rates of ADEs might be considered for effective treatment instead of mefloquine and quinine.
Key words: Plasmodium, imported malaria, adverse drug events, mefloquine, quinine Malaria is one of the most severe public health problems world- ia-endemic counties for vacation or missionary works. About wide. It is a leading cause of disease and death in many devel- 40-80 cases of imported malaria have been diagnosed in South oping countries. An estimated 1 million deaths occur every year Korea per year [4,5]. However, the above studies reported only due to malaria [1]. Malaria due to Plasmodium vivax, the only the clinical epidemiology of imported malaria in Korea [3,5].
naturally occurring human malaria in Korea, was endemic to The clinical characteristics and treatment outcomes of import- Korea until the late 1970s, when the country became malaria ed malaria in South Korea have not been previously reported.
free. After its first reemergence in 1993, the prevalence of malar- We therefore systematically reviewed the clinical characteristics ia increased exponentially, peaking in 2000, and since then the and treatment outcomes of imported malaria, and also assessed rates of infection have been decreasing. In total, 21,419 cases the frequency of adverse drug events (ADEs) associated with the were reported between 1993 and 2005 in South Korea [2]. In first line therapeutic anti-malarial regimens. the 1960s and 1970s, many cases of imported malaria were Imported malaria was defined as a positive smear for malaria reported in Korea because of the participation of Korean troops acquired in another country, outside of South Korea. The med- in the Vietnamese War as Allied Forces in 1965 [3]. Recently, ical records were retrospectively reviewed among all patients an increasing number of Koreans have been traveling to malar- with imported malaria diagnosed at the Samsung Medical Center(SMC) from January 1995 to December 2007. The diagnosiswas based on microscopic examination of thick and thin blood ● Received 14 November 2008, revised 17 April 2009, accepted 16 May 2009.
smears. Severe malaria was defined according to the World Health * Corresponding author (krpeck@skku.edu)�HS Cheong and KT Kwon contributed equally to this study. Organization (WHO) criteria [6]. We reviewed the electronic Korean J Parasitol. Vol. 47, No. 3: 299-302, September 2009
database of medical records to analyze the travel history, use of binemia over 3.0 mg/dl was detected in 13 patients (92.9%), chemoprophylaxis, clinical features, species of Plasmodium detect- disseminated intravascular coagulation (DIC) in 7 patients (50.0 ed, complications, treatment, and outcome. The time to defer- %), pulmonary edema in 5 patients (35.7%) and parasitemia vescence was defined as the interval from initiation of appro- over 5% in 4 patients (28.6%) (Table 3). An exchange transfu- priate antimalarial treatment until the documentation of nor- sion was performed in 3 patients infected with P. falciparum. The mal body temperature for more than 24 hr.
median number of days to defervescence was 3.6 days (range During the study period, 49 patients were diagnosed with im- 2-7 days). All patients except 1 survived. Mefloquine was the ported malaria in SMC. Thirty-five patients were infected with most frequently prescribed medication (38/49, 77.6%). Quinine only Plasmodium falciparum, while 8 patients were diagnosed with was used in 9 patients (9/49, 18.4%) (Table 4). Among the only P. vivax infection. There were 2 cases of mixed infections mefloquine-treated patients, 7 had gastrointestinal symptoms, with P. falciparum and P. vivax or P. falciparum and Plasmodium such as nausea and vomiting. Among the quinine-treated ovale. The exact species of the other cases (N = 4) were undeter- patients, 5 developed cinchonism, seizures, and vomiting (Table mined. There were 38 male and 11 female patients. Their agewas 35.7 ± 11.0 year (12-58 year). The epidemiological char- Table 2. Clinical and laboratory findings at presentation acteristics are described in Table 1. Africa appeared to be the most common region of acquisition of infection (27/47, 55.1%).
Business (15/49, 30.6%) was the most common purpose of travel, followed by missionary works (14/49, 28.6%). Table 2 shows the clinical and laboratory findings of the patients at pre- sentation. In all cases, fever was the presenting symptom. At presentation, 35 (71.4%) patients had abnormal liver enzyme levels, and 30 (61.2%) had thrombocytopenia (i.e., platelets < 100,000/μl). According to the WHO severe malaria criteria, 14 patients were classified as having severe malaria: hyperbiliru- Table 1. The characteristics of patients with imported malaria AST, aspartate aminotransferase; ALT, alanine aminotransferase.
Table 3. Findings associated with severe malaria aIncluding 2 mixed infection cases with P. falciparum and P. vivax or P. aAll cases are Plasmodium falciparum infection.
falciparum and P. ovale.
DIC, disseminated intravascular coagulation. Cheong et al.: Imported malaria in Korea: experience in a single center 301 Table 4. Therapy and outcomes of patients with imported malaria Table 5. Adverse events associated with mefloquine and quinine malaria in adults. In order to use intravenous quinine and arte- sunate, clinicians have to formally request these agents to the National Medical Center. In our study, about 1/5 of the patients who were taking mefloquine had gastrointestinal symptoms, such as nausea and vomiting. ADEs leading to discontinuation of treatment occurred in 13.2% of the patients treated with meflo- quine. By contrast, Ki et al. [8] reported that mefloquine based chemoprophylaxis was well tolerated in Korean patients; only 0.6% of patients receiving mefloquine had ADEs. This difference in the frequency of ADEs with mefloquine treatment might be Total number exceeds 49 because secondary treatment agents are in-cluded.
attributed to the difference in the doses used and the patient’sgeneral condition.
5). Five patients (13.2%) among the mefloquine-treated group It is well known that multidrug-resistant falcifarum malaria and 4 patients (44.4%) treated with quinine had to be treated emerged in Southeast Asia, especially at the border between Thai- with alternative antimalarial agents due to ADEs.
land and Myanmar or Thailand and Cambodia. Because many P. falciparum infection accounted for 70.3% (N = 26) of cases Koreans visit Thailand and Cambodia, healthcare-providers must from Africa (all cases developed in sub-Saharan Africa), 16.2% be aware of potential resistance when treating patients returning (N = 6) from Southeast Asia, and 10.8% (N = 4) from South from these areas [9]. With the increase in international travels, Asia. These proportions were similar to the data from the Korean imported malaria might become a more common problem for Center for Disease Control and Prevention [4]. Severe malaria healthcare providers. Improved educational programs for over- attacks occurred in 14 patients infected with P. falciparum. Severe seas travelers should help reduce the number of imported malar- P. falciparum malaria accounted for 64.3% (N = 9), and 35.7% ia cases in Korea. To reduce the morbidity and mortality related (N = 5) of infections from Southeast or South Asia. Because to imported malaria, travelers must be informed of the malaria severe malaria is caused by P. falciparum, rapid diagnosis and risks, the necessity of chemoprophylaxis, and the importance of immediate medical care if fever develops.
Malaria caused by P. falciparum is becoming resistant to anti- malarials. Multidrug resistant malaria is one of the most signif- ACKNOWLEDGEMENTS
icant therapeutic problems in Africa and Southeast Asia. Mostof the imported malaria identified in this study developed after A part of this study was presented at the 17th International traveling to Africa or Southeast Asia (77.5%). Therefore, com- Congress for Tropical Medicine and Malaria (ICTM), Jeju Island, bination treatment is recommended for a first-line treatment of falciparum malaria from Africa and Asia [7]. However, meflo-quine may be effective against imported malaria, especially aga- REFERENCES
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