Malaria and Travel to the Dominican Republic

To the Editor: The rise in international travel to malaria-endemic areas in recent years has been followed by an increase in the number of cases diagnosed in countries where malaria is not endemic (1). Tourist areas of the Dominican Republic have traditionally been considered to be low risk for malaria transmission. However, over the past few years, sporadic descriptions of imported falciparum malaria in travelers to these destinations have been described (2,3). In spite of these findings, neither the World Health Organization nor the Centers for Disease Control and Prevention recommend antimalarial chemoprophy-laxis for trips to the Dominican Republic's main tourist resorts (4,5). We report a new case of imported malaria caused by mixed Plasmodium vivax and P. malariae infection, with unique clinical features, after a standard tourist trip to Puerto Plata (on the northern coast of the Dominican Republic). A 31-year-old man with no relevant medical history was treated in the internal medicine department of our hospital. He reported a history of poorly defined malaise, night sweats, sleeplessness , tinnitus, and episodic diarrhea with no pathologic products during the previous 6 days. He did not report fever, chills, or headache. Two weeks earlier, he had spent 10 days in Puerto Plata in a tourist resort, without traveling to any other place. He had not received any antimalarial chemopro-phylaxis. Physical examination showed no abnormalities. Laboratory values, including levels of sodium, potassium, liver enzymes, creatinine, and coagulation factors, as well as results of hemogram and chest radi-ograph, were within normal limits. A blood film showed trophozoytes of P. vivax and P. malariae. In a stool specimen , Entamoeba histolytica, Trichiuris trichura, Endolimax nana, and Blasto-cystis hominis were observed; stool cultures were negative. Treatment was initiated with chloroquine (4 doses) and primaquine for a period of 14 days; metronidazole and paromomycin were administered for the intestinal infestations. Symptoms resolved in 48 hours, and control blood films showed clearance of the parasitemia. Two months after the end of treatment, the patient remained asymptomatic. We describe a new and unusual case of imported vivax-malariae malaria. Two characteristics of our patient's case bear mention. First, the place of acquisition of the infection and the species of Plasmodium involved are notable. The Dominican Republic is considered a low-risk area for malaria, although some places in the west, on the Haitian border, are malaria-endemic. In addition, according to available information, autochthonous malaria cases increased after Hurricane George …