Artesunate and dihydroartemisinin-piperaquine treatment failure in a severe Plasmodium falciparum malaria case imported from Republic of Côte d'Ivoire.

A 68-year-old man returning from Republic of Côte d'Ivoire (Ivory Coast) was diagnosed with severe Plasmodium falciparum malaria and treated with intravenous artesunate followed by oral dihydroartemisinin-piperaquine (DHA-PPQ). A month later the patient experienced a new P. falciparum episode; analysis of pfmsp-1 and pfmsp-2 revealed that the infection was caused by a genetic strain identical to the strain that caused the initial episode, indicating resurgence of the previous infection. No mutations in genes associated with resistance to artemisinin derivatives (pfk13) or piperaquine (pfexonuclease, pfplasmepsin 2/3) were detected, suggesting that treatment failure could have been caused by drug malabsorption or poor drug manufacturing practices. A second treatment with atovaquone-proguanil was successful in eliminating the infection, with no further relapses. To our knowledge, this is the first description of a treatment failure with both artesunate and DHA-PPQ in a traveler returning from a malaria-endemic region. Analysis of molecular markers of resistance to antimalarial drugs revealed mutations associated with resistance to sulfadoxine (pfdhps) and pyrimethamine (pfdhfr), highlighting the important contribution of surveillance of imported malaria cases to the monitoring of drug resistance globally.

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