A severe case of Plasmodium falciparum malaria in a traveler returning from Kazakhstan, a malaria-free country

•Plasmodium falciparum infection established from a retuning traveler from Kazakhstan.•Kazakhstan was declared malaria-free in 2012.•Patient had no travel history outside Europe, other than Kazakhstan.•Molecular tests done in Germany confirmed parasites belong to a NF54 type of African origin.•The possibility of airport malaria cannot be ruled out. Following a 2-week trip to Kazakhstan, a 42-year-old woman presented at the emergency department in Germany with fever, headache, nausea, and neurological symptoms. An infection with Plasmodium falciparum was rapidly diagnosed. The patient was immediately treated with intravenous artesunate and transferred to an intensive care unit. The initial parasite density was as high as 30% infected erythrocytes with 845,880 parasites/µL. Since Kazakhstan was declared malaria-free in 2012, molecular testing for Plasmodium has been initiated to identify a possible origin. Genotyping of the msp-1 gene and microsatellite markers showed that the parasites are of African origin, with two different alleles indicating a polyclonal infection. After a hospitalization of 10 days, the patient was discharged in good health. Overall, our results emphasize that malaria must be on the list of differential diagnoses for patients with fever of unknown origin, even if they come from countries where malaria does not commonly occur.