Thrombocytopenia is a common and usually self-limiting feature of malaria, but a markedly low platelet count can make emergency caesarean delivery for non-reassuring fetal status a high-risk undertaking where platelet concentrates and fresh frozen plasma are unavailable. We report a case in which this constraint, arising from late-pregnancy P. falciparum malaria initially referred as suspected pre-eclampsia, led to a period of maternal treatment, intrauterine resuscitation and close surveillance rather than immediate operative delivery. A 31-year-old Ghanaian woman, gravida 5 para 3 with one previous spontaneous abortion, at 37 weeks + 2 days dated by a reliable first-trimester scan, was referred with suspected pre-eclampsia (blood pressure 144/96 mmHg, dipstick proteinuria positive, fetal heart rate 165 beats/min), reduced fetal movement and lower abdominal pain, two weeks after oral artemether-lumefantrine for malaria. On arrival, blood pressure was 135/68 mmHg, dipstick proteinuria was negative, and cardiotocography showed a baseline of 179–186 beats/min with moderate variability, accelerations present and no decelerations. Microscopy identified P. falciparum trophozoites (22,268 parasites/µL); haemoglobin was 8.9 g/dL, platelet count was 37 × 109/L (severe thrombocytopenia) and urinalysis showed ketonuria (+ + + ). The available record did not document a WHO severe malaria feature and repeat assessment did not support pre-eclampsia or HELLP syndrome. With platelet concentrates and fresh frozen plasma unavailable, immediate caesarean delivery was considered high risk. The treating team gave intrauterine resuscitation (intravenous fluids, left lateral position and oxygen), intravenous artesunate (2.4 mg/kg; 204 mg at 0, 12 and 24 h) and close maternal–fetal surveillance with stated criteria for escalation to delivery. Fetal tachycardia improved within 6–8 h and resolved by 24 h; the platelet count rose from 37 to 91 and 137 × 109/L by hospital day 4. At 39 weeks, after obstetric reassessment, labour was induced. She delivered vaginally a 3.6-kg infant with Apgar scores of 8 and 9 at 1 and 5 min, respectively. Mother and infant remained clinically well through six weeks of two-weekly follow-up. Thrombocytopenia is a common complication of malaria in pregnancy, including uncomplicated malaria, and usually recovers with effective antimalarial treatment. When fetal tachycardia complicates late-pregnancy malaria, treatable maternal causes should be addressed first; in resource-constrained settings without platelet or plasma support, time-limited maternal treatment with close fetal surveillance and explicit escalation criteria may be safer than immediate operative delivery. The case also illustrates recurrence of parasitaemia two weeks after a standard three-day artemether-lumefantrine course in late pregnancy, when drug exposure is known to be reduced, although recurrence could not be distinguished from reinfection. The favourable outcome does not establish the safety or effectiveness of expectant management but highlights the need to document and balance competing maternal and fetal risks.
Antimalarial drug resistance (AMDR) continues to threaten malaria control and elimination, underscoring the need for timely and reliable malaria molecular surveillance. Data generation through therapeutic efficacy studies (TES) and independent surveys is critical, yet limited guidance exists to support policymakers and National Malaria Control Programs (NMCPs) in selecting appropriate laboratory techniques for different surveillance objectives and operational contexts. This descriptive technical review aimed to assess the currently used laboratory techniques based on their technical and operational characteristics, identify knowledge gaps and provide decision support for Malaria Molecular Surveillance (MMS) of Plasmodium falciparum. The literature search was conducted in PubMed and supplemented by citation searching. Following title and abstract screening, data were extracted on predefined performance, operational, and technical characteristics. A non-exclusionary assessment of reporting quality was also performed. The results were reviewed by field experts, who added additional information, based on the findings. Thirty-nine studies published between 1998 and 2025 met the inclusion criteria. Performance varied between PCR-based and sequencing-based techniques, with analytical sensitivity ranging from 1–1000 parasites/µL for PCR-based techniques, and 1–2000 parasites/µL for sequencing-based techniques. Clinical sensitivity and specificity were high across all techniques, though highest for sequencing-based methods. PCR-based techniques provided rapid results and required less infrastructure for the targeted detection of known SNPs but could not identify novel markers. Sequencing-based techniques offered high multiplexing potential and could often detect minority variants and discover novel markers. However, they required greater capital investment, more extensive training, and substantial bioinformatics capacity. Cost data were highly variable and often incompletely reported, highlighting a knowledge gap. We developed a structured decision-support framework, illustrated through three hypothetical country scenarios reflecting differing surveillance needs, laboratory capacities, and resource constraints. These examples demonstrate that no single method is universally optimal and that technique selection should be tailored to specific surveillance objectives, epidemiological context, existing infrastructure, budget, and long-term capacity-building goals. This review provides an updated overview of available techniques and practical guidance to support stakeholders in selecting accurate, feasible, and sustainable approaches for monitoring AMDR through MMS, while also highlighting key knowledge gaps.
Malaria remains a significant public health challenge in Ethiopia. Access to malaria information and prevention is shaped by gender together with other social factors such as poverty, education, residence, and cultural norms. This study applied an intersectional gender lens to examine how these factors influence malaria information access, knowledge, and attitudes in Jimma Zone, Oromia Region. An exploratory sequential mixed-methods study was conducted in 2023. The qualitative phase included 12 focus group discussions, 11 key informant interviews, and 2 in-depth interviews with 118 participants. A subsequent community-based survey included 2,198 adults (1,086 females and 1,112 males). Knowledge was assessed using 17 items and attitudes using 31 items across five constructs. Quantitative findings were disaggregated by sex and examined across age, education, residence, and wealth. Qualitative data were analyzed thematically and integrated at interpretation. Overall exposure to malaria information was similar among females and males (51.7
Routine monitoring of antimalarial drug efficacy is essential to guide national malaria treatment policies and ensure the continued effectiveness of first- and second-line therapies. Artemisinin-based combination therapies (ACTs) have been recommended in Mauritania since 2006. Artemether–lumefantrine (AL) is currently used as second-line treatment for uncomplicated Plasmodium falciparum malaria. This study assessed the therapeutic efficacy of AL and investigated P. falciparum kelch13 (pfk13) polymorphism associated with artemisinin partial resistance. A prospective single-arm, therapeutic efficacy study was conducted between August and October 2023 in two sentinel sites in southeastern Mauritania (Kobeni and Timbedra). Patients aged ≥ 6 months with uncomplicated P. falciparum mono-infection were enrolled and treated with a standard six-dose regimen of AL over three days. Patients were followed for 28 days, in accordance with WHO 2009 guidelines. Treatment outcomes were classified as early treatment failure, late clinical failure, late parasitological failure, or adequate clinical and parasitological response (ACPR). PCR genotyping was performed to distinguish recrudescence from reinfection. Day 0 samples were analysed for mutations in the pfk13 propeller-encoding domain. A total of 132 patients were enrolled, of whom 121 completed the 28-day follow-up. Two recurrent infections were detected in Kobeni and were confirmed as recrudescence by molecular genotyping. The PCR-corrected ACPR was 96.6
Neurological complications are among the most severe manifestations of Plasmodium falciparum malaria. Cerebral malaria is the best-recognized neurological syndrome; however, malaria-associated brain injury involves a broad spectrum of inflammatory, vascular, and immune-mediated processes. Limbic encephalitis is characterized by inflammation involving the medial temporal structures, and is most commonly associated with viral infections, particularly herpes simplex virus (HSV), or autoimmune disorders. Malaria-associated limbic encephalitis remains poorly characterized. We describe two adult male patients with severe P. falciparum malaria complicated by a clinico-radiological phenotype consistent with limbic encephalitis, identified through clinical presentation, magnetic resonance imaging (MRI), cerebrospinal fluid (CSF) analysis, and exclusion of alternative infectious causes; neither case fulfilled formal criteria for a definite diagnosis, as anti-neuronal antibody testing was not performed. The first patient, a 47-year-old previously healthy male, developed progressive altered sensorium, seizures, and respiratory failure requiring intensive care admission and mechanical ventilation, with acute liver injury and metabolic acidosis. EEG showed diffuse cerebral dysfunction with an electrographic seizure arising from the left posterior region. MRI demonstrated bilateral hippocampal/amygdalar T2/FLAIR hyperintensity with mild diffusion restriction on DWI and no hemorrhage. CSF was mildly inflammatory with negative multiplex PCR, including HSV. Intravenous immunoglobulin was added to antimalarial therapy given the severity of illness, and the patient achieved complete clinical recovery at hospital discharge. The second patient, a 25-year-old previously healthy male, presented with confusion and recurrent generalized seizures. MRI showed diffuse left hippocampal T2/FLAIR hyperintensity without hemorrhage or true diffusion restriction on DWI. CSF and multiplex PCR testing for bacterial, viral, and fungal pathogens were unremarkable. The patient improved with standard antimalarial and antiseizure therapy alone and achieved complete clinical recovery at hospital discharge. Malaria-associated limbic encephalitis is an uncommon but clinically important neurological phenotype of severe P. falciparum malaria, although the diagnosis in this series remains presumptive in the absence of anti-neuronal antibody testing. Recognition of the characteristic mesial temporal MRI abnormalities and exclusion of alternative causes of encephalitis may assist clinicians in identifying such patients. Further studies are needed to clarify the mechanisms, diagnostic criteria, and potential role of immunomodulatory therapy in this condition.
