14 In our series, patients coming from Africa were more likely to be infected with P falciparum (96.5%), whereas Enzalutamide those coming from the Indian subcontinent or Southeast Asia were infected with P vivax in more than half of cases. A study of imported malaria performed in France regarding over 2,000 cases showed similar results with 94% of infections acquired in Africa and 80% of cases due to P falciparum.15 It is well known that marked regional difference exists in the species of Plasmodium identified among different published

series with P falciparum accounting for over 80% in Europe,4,5,14–19 whereas in North America3,20–22 and the Pacific region P vivax is diagnosed in 54% to 59% of imported cases.23,24 In this regard, travel history can provide Birinapant mw useful clues in determining the responsible

Plasmodium spp. when the microscopical diagnosis is uncertain. In our investigation the majority of patients who acquired malaria were not taking drugs for chemoprophylaxis or were non-compliant with the prescribed regimens—a data consistent with the 11% to 51% prevalence reported in previous studies.3,18,20–22 However, among those taking malaria chemoprophylaxis the highest rates of use were observed among tourists while the lowest among immigrants, thus corroborating previously reported figures.20,25 Worth noting, 72.2% of the 18 patients who developed malaria despite mefloquine prophylaxis, had P vivax or P ovale infections suggesting that even with effective chemoprophylaxis patients remain at risk for relapsing infections caused by hypnozoites. The

absence of pharmacokinetic/pharmacodynamic data about mefloquine in the five patients with P falciparum malaria makes elusive any conclusion about resistance. Clinical symptoms of imported malaria are not specific and thus their value is high only in the context of a carefully taken travel history. Moreover, case-control studies demonstrated that the only strong predictors of imported Doxorubicin malaria were an enlarged spleen, hyperbilirubinemia, and thrombocytopenia,17,18,26 but splenomegaly (28.7%) and jaundice (11.5%) are only rarely observed. On the contrary, a platelet count below 150,000/µL was observed in 82% of our patients that is slightly higher than the 62.9% figure (range 50%–82%) reported in several studies.16,20,22,24 Although a recent study demonstrated that no single clinical or biological feature had both good sensitivity and specificity to predict malaria in febrile travelers, thrombocytopenia was the single most sensitive criterion (98.1%) and with a relatively high specificity (82.6%).26 A first problem about management of malaria emerging from our study concerns the fact that in about 50% of patients, levels of parasitemia were not checked at the time of initial diagnosis. However, this unacceptable high inaccurate laboratory diagnosis was observed mainly in cases diagnosed before 2002 (data not shown).