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Learning objectives
As a result of climate change and humanitarian crises, health practitioners worldwide are facing growing incidences of infectious diseases such as malaria.
Practitioners need to become acquainted with the epidemiology of malaria endemic regions, clinical and diagnostic implications, and specific treatments for
the different Plasmodium species.

Case
A 19-year-old Afghan refugee fled to Switzerland by air, after a 10-day interim stay in Pakistan. Ten months later he experienced fever, flu-like symptoms
and myalgia. On his second visit to the general practitioner, the patient was referred to the local hospital where he tested positive for malaria. Hospital
admission followed due to high fever, hemodynamic instability and difficulty swallowing medication. Further evaluation revealed thrombocytopenia,
hemolysis and splenomegaly. The Giemsa blood smear showed parasitemia of 1%, with microscopy confirming Plasmodium vivax. Clinical improvement
occurred within 24 hours after artesunate therapy, enabling a treatment with chloroquine. After five days, parasitemia was no longer detected. Since P.
vivax can cause relapses, adding primaquine is essential. Symptoms improved quickly and the patient recovered fully within one month.

Discussion
Malaria should be suspected in patients with fever and a travel history to endemic regions. Malaria tropica (P. falciparum) occurs mainly in sub-Saharan
Africa, within one month after exposure. In contrast, M. tertiana (P. vivax and ovale) is prevalent in the Indian subcontinent and can develop months after
transmission. Although P. vivax is regarded as a “milder” variant, our patient developed severe M. tertiana after a 10-month incubation period and initial
delay in diagnosis. Since Afghanistan and Pakistan are endemic for P. vivax , our patient could have contracted malaria in either country. In recent years, the
Indian subcontinent has been hit by extreme weather conditions, linked to climate change. Pakistan, has been deluged by flooding, consecutively from 2020
to 2022. This has led to the expansion of breeding grounds for the Anopheles mosquito and outbreaks of M. tertiana. Afghanistan is also facing a
humanitarian crisis with migration to adjourning countries like Pakistan and beyond. Primary care physicians can expect to see a rise in malaria cases from
this region.