Le infezioni in medicina · 2026
Epidemiology of imported malaria in an area of North-Eastern Italy (2016-2025): clinical focus on cerebral malaria.
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Corich Lucia, Bortolin Maria Teresa, Tedeschi Rosamaria, Casarotto Mariateresa, Pancino Antonella, Molaro Alberto, Anzanello Valentina, Basaglia Giancarlo, Corich Maria Ada
Аннотация
BACKGROUND: In non-endemic settings, imported malaria poses diagnostic challenges due to non-specific presentations and lack of immunity, especially in visiting friends and relatives (VFRs). Focusing on the Western Friuli (Italy) observatory, this work aims to optimize triage by identifying early severity predictors. Through the analysis of clinical parameters, paediatric cerebral cases, and host genetics - including an illustrative case of HbS/β-thalassaemia - we evaluate the drivers of Plasmodium falciparum progression to improve patient management.
METHODS: This retrospective study (2016-2025) analysed symptomatic malaria cases in the Friuli Occidentale Health Authority, combining epidemiological data with illustrative clinical cases. Diagnosis was confirmed via microscopy and molecular methods. Using WHO/AMCLI criteria, we evaluated admission parameters, including procalcitonin (PCT), C-reactive protein (CRP), and platelet count, to identify predictors of severe malaria, adopting a ≥2% parasitaemia threshold. Diagnostic accuracy was assessed via multivariable logistic regression and ROC analysis.
RESULTS: Of the 124 malaria cases (P. falciparum 88.71%), 90.32% were VFRs, primarily from West Africa; only 12% reported adequate prophylaxis. Severe malaria occurred in 19.35% (24/124), including two cerebral malaria (CM) cases, with no fatalities. Severity fluctuated significantly, peaking at 60% (6/10; 95% CI 26.2%-87.8%) in 2025. Multivariable analysis identified parasitaemia ≥2% (aOR 8.44; 95% CI 2.41-29.58; p=0.001) and PCT (aOR 1.23; 95% CI 1.06-1.42; p=0.007) as the only independent severity predictors. PCT outperformed CRP (AUC 0.84 vs 0.73); at a 5.10 ng/mL cut-off, PCT demonstrated a 95.9% negative predictive value (NPV), effectively identifying low-risk patients. CM Case 1 (2017): A 5-year-old male with HbS/β-thalassaemia (VFR, from Ghana) admitted for P. falciparum malaria (9.5% parasitaemia) and severe anaemia, evolving into CM (loss of consciousness, seizures, BCS score 0); successfully treated with IV artesunate, antiepileptics, and blood transfusions, without sequelae. CM Case 2 (2022): A 3-year-old male (VFR, from Burkina Faso) with P. falciparum malaria (12.6% parasitaemia) evolving into CM (altered state of consciousness, EEG signs of cerebral distress, retinal haemorrhage, BCS score 2); resolved with IV artesunate and antiepileptics without sequelae.
CONCLUSIONS: Imported malaria remains a critical challenge due to unpredictable severity trends and non-specific onset of CM. PCT, combined with parasitaemia, outperformed CRP and platelet count as an independent predictor of severity. High PCT levels should serve as a "red flag" for immediate triage and parenteral therapy. Integrating PCT into clinical guidelines is essential for effective risk stratification and preventing life-threatening complications in non-endemic settings.
METHODS: This retrospective study (2016-2025) analysed symptomatic malaria cases in the Friuli Occidentale Health Authority, combining epidemiological data with illustrative clinical cases. Diagnosis was confirmed via microscopy and molecular methods. Using WHO/AMCLI criteria, we evaluated admission parameters, including procalcitonin (PCT), C-reactive protein (CRP), and platelet count, to identify predictors of severe malaria, adopting a ≥2% parasitaemia threshold. Diagnostic accuracy was assessed via multivariable logistic regression and ROC analysis.
RESULTS: Of the 124 malaria cases (P. falciparum 88.71%), 90.32% were VFRs, primarily from West Africa; only 12% reported adequate prophylaxis. Severe malaria occurred in 19.35% (24/124), including two cerebral malaria (CM) cases, with no fatalities. Severity fluctuated significantly, peaking at 60% (6/10; 95% CI 26.2%-87.8%) in 2025. Multivariable analysis identified parasitaemia ≥2% (aOR 8.44; 95% CI 2.41-29.58; p=0.001) and PCT (aOR 1.23; 95% CI 1.06-1.42; p=0.007) as the only independent severity predictors. PCT outperformed CRP (AUC 0.84 vs 0.73); at a 5.10 ng/mL cut-off, PCT demonstrated a 95.9% negative predictive value (NPV), effectively identifying low-risk patients. CM Case 1 (2017): A 5-year-old male with HbS/β-thalassaemia (VFR, from Ghana) admitted for P. falciparum malaria (9.5% parasitaemia) and severe anaemia, evolving into CM (loss of consciousness, seizures, BCS score 0); successfully treated with IV artesunate, antiepileptics, and blood transfusions, without sequelae. CM Case 2 (2022): A 3-year-old male (VFR, from Burkina Faso) with P. falciparum malaria (12.6% parasitaemia) evolving into CM (altered state of consciousness, EEG signs of cerebral distress, retinal haemorrhage, BCS score 2); resolved with IV artesunate and antiepileptics without sequelae.
CONCLUSIONS: Imported malaria remains a critical challenge due to unpredictable severity trends and non-specific onset of CM. PCT, combined with parasitaemia, outperformed CRP and platelet count as an independent predictor of severity. High PCT levels should serve as a "red flag" for immediate triage and parenteral therapy. Integrating PCT into clinical guidelines is essential for effective risk stratification and preventing life-threatening complications in non-endemic settings.