Plasmodium falciparum found in the bone marrow of a child in Manado City, East Indonesia: A case report

In Indonesia, there are at least 1.3 million cases of malaria each year and Plasmodium falciparum appears to be the most common Plasmodium. The finding of Plasmodium is important for the diagnosis and management of malaria. This is a case of a 4-year-and-9-month-old male who lived in Manado, East Indonesia. He presented with a prolonged fever, was pale in appearance, and was easily fatigued over the last 3 weeks. Hepato-splenomegaly was found on the initial physical examination. Preliminary laboratory findings found pancytopenia and severe anemia. Before he was referred to our hospital, at the primary health center, the initial work-up was negative for Plasmodium with the serial Rapid Diagnostic Test and microscopic peripheral blood smears. Since there were signs and symptoms mimicking malignancy, the patient was referred to our hospital for further malignancy work-up. A bone marrow puncture was done and we incidentally found Plasmodium falciparum in a microscopic bone marrow smear. This was a rare case because Plasmodium was not initially found in the preliminary work-up (Rapid Diagnostic Test and Microscopic) and qPCR is not a routine work-up for Plasmodium suspected patients. Although the mortality rate of malaria is high, this condition can be treated if the clinician was aware of the clinical signs and symptoms in the early onset and prompt medical treatment is administered. In a severe case with an unclear etiology of fever and with signs and symptoms mimicking malignancy, qPCR is recommended. However, a bone marrow puncture can also be considered to exclude the possibility of a malaria infection.