Background
Malaria remains a major global public health challenge, with an estimated hundreds of millions of cases annually and substantial associated morbidity and mortality, particularly in sub-Saharan Africa. Despite being non-endemic in the United States, imported malaria continues to occur, most commonly among travelers returning from endemic regions. Among these, individuals visiting friends and relatives (VFR travelers) represent a disproportionately high-risk population. This increased risk is multifactorial, including reduced engagement with pre-travel healthcare services, lower uptake of chemoprophylaxis, longer duration of travel, and greater likelihood of staying in high-transmission or rural settings. This case highlights both the clinical presentation of imported Plasmodium falciparum malaria and the broader gaps in prevention and risk perception in this vulnerable population.

Case Presentation

A 35-year-old male with an unremarkable past medical history presented with progressive fatigue, jaundice, and intermittent paroxysmal fevers following recent travel to Morocco and Nigeria. His travel was notable for visiting friends and relatives (VFR) and spending time within local community settings. Notably, he had not sought pre-travel medical consultation or initiated malaria chemoprophylaxis. Upon clinical evaluation in the United States, the patient was febrile to 101.8°F and reported worsening malaise and diminished exercise tolerance. Physical examination revealed scleral icterus and generalized fatigue without focal findings. Laboratory investigations demonstrated leukocytosis, hyponatremia, and hyperbilirubinemia, with an elevated lactate dehydrogenase level consistent with hemolysis. Further workup identified a previously undiagnosed glucose-6-phosphate dehydrogenase (G6PD) deficiency. In light of his travel history and clinical presentation, a peripheral blood smear was obtained, revealing Plasmodium falciparum trophozoites within the erythrocytes. The patient was admitted for close clinical monitoring and serial laboratory evaluation. He received treatment with atovaquone-proguanil, resulting in rapid clinical improvement and eventual complete recovery. No severe complications, such as cerebral malaria or acute respiratory distress syndrome, developed during his hospitalization.