Recrudescent severe malaria due to Plasmodium falciparum following treatment in a Taiwanese patient: a case report.

backgroundSevere malaria caused by Plasmodium falciparum remains a life-threatening disease, particularly in non-immune individuals returning from endemic regions. While prompt treatment can usually achieve parasite clearance, recrudescence after initial recovery is rare and presents unique diagnostic and management difficulties. This report documents a case of recrudescent severe malaria in a Taiwanese traveller, highlighting the complexity of managing in the setting of multi-organ failure, even with guideline-based therapy. CASE PRESENTATION: A previously healthy 66-year-old Taiwanese man developed fever, vomiting, diarrhoea, and jaundice shortly after returning from multiple Central African countries with high malaria prevalence. His condition rapidly deteriorated to multi-organ failure, including acute kidney injury, liver failure, thrombocytopenia, and respiratory distress. Blood smear microscopy revealed a high parasitaemia (20%) due to P. falciparum, which was confirmed by real-time PCR. MANAGEMENT AND OUTCOME: The patient received intravenous artesunate and oral artemether-lumefantrine, in addition to haemodialysis and plasma exchange as supportive therapies. Initial treatment achieved parasite clearance and clinical improvement. However, 4 weeks later, the patient experienced recrudescence with recurrent fever, anaemia, and return of parasitaemia. The therapeutic regimen was then revised to artesunate combined with doxycycline and clindamycin, followed by oral artemether-lumefantrine. This approach led to successful parasite clearance within 2 weeks and complete recovery, with no further recurrence observed during follow-up.

conclusionsThis case highlights that even with prompt, guideline-based therapy and the absence of pfk13 mutations, severe P. falciparum malaria in non-immune individuals can still develop recrudescence. Enhanced clinical vigilance, laboratory monitoring, and multidisciplinary care are essential for management. Reporting such rare recrudescent cases supports clinical awareness, informs best practice, and strengthens public health preparedness in low-incidence regions.