Possible transmission of Plasmodium malariae through liver transplantation: Diagnosis with a Sysmex XN-20™ hematology analyzer

Malaria is an infectious disease caused by several species of the genus Plasmodium. It is usually transmitted by female Anopheles mosquitoes. Other routes of transmission include mother-to-child transmission, shared use of needles, blood transfusion and solid organ transplantation. In non-endemic countries, malaria is often diagnosed on the basis of a history of journeys or migration from endemic areas. Transplant-transmitted malaria might represent a diagnostic challenge for clinicians. Here, we report the casual diagnosis of possible transplant-transmitted malaria in a Spanish patient with no previous visits to endemic areas. He developed symptoms one month after receiving a liver transplant from a deceased donor immigrated from Ghana. After being admitted to the Emergency Room, a complete blood count revealed an abnormal cell population which activated an 'infested red blood cells' flag (iRBC). This finding led to perform a blood smear and further tests which confirmed the diagnosis of malaria. Given that automated complete blood counts are usually performed for any patient with fever, they represent a useful tool to detect malaria in unsuspected patients. In particular, the iRBC flag implemented in Sysmex XN-Series™ hematology analyzers is a useful screening tool for malaria in clinical laboratories.