Epidemiologic Notes and Reports Imported Malaria Associated with Malariotherapy of Lyme Disease -- New Jersey

In November 1990, a physician in New Jersey reported two cases of imported vivax malaria to the New Jersey State Department of Health. Both of these patients were among five patients who had been diagnosed with late-stage Lyme disease and referred by the physician to sources in Mexico for intramuscular injections of blood containing Plasmodium vivax parasites. The malaria donors reportedly had been screened for serologic evidence of syphilis, hepatitis B, and human immunodeficiency virus infection. On return to New Jersey, the two patients were diagnosed with parasitemia 3 days and 14 days after the injection, respectively. Approximately 3 weeks after onset of malaria, the patients were treated with chloroquine with satisfactory response. Reported by: K Mertz, MD, KC Spitalny, MD, State Epidemiologist, New Jersey State Dept of Health. Bacterial Zoonoses Br, Div of Vector-Borne Infectious Diseases and Malaria Br, Div of Parasitic Diseases, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Lyme disease, caused by the tick-transmitted spirochete Borrelia burgdorferi, is a zoonotic disease with protean clinical manifestations, including late-stage arthritic and neurologic manifestations (1). Lyme disease has been reported from 46 states and is highly endemic in some areas of the northeastern and mid-Atlantic regions (including New Jersey), the north central region, and the Pacific coastal region (2). Antibiotics are effective in treating both early and late stages of Lyme disease (1,3). In some patients, however, symptoms persist despite appropriate treatment (3,4). Causes could include persistent spirochetosis (5), irreversible tissue damage (3,4), autoimmunity (3), and misdiagnosis (6).

Induced vivax malaria recently was proposed for the treatment of neuroborreliosis (7). The precedent for this approach is the obsolete practice of malariotherapy for the treatment of neurosyphilis, which was widely used in the preantibiotic era (8). Controlled studies of malariotherapy for neurosyphilis never were done; published results suggested that the response to treatment was unpredictable and primarily clinical and that the duration of remission was variable (9). Changes in serologic status generally did not correlate with clinical improvement, suggesting that malariotherapy had minimal, if any, effect on the underlying spirochetal infection (9). Malariotherapy for syphilis was discontinued when penicillin and other effective antibiotics became available.

For at least three reasons, induced malaria is not recommended for the treatment of Lyme disease. First, no scientific studies exist of the efficacy of this procedure for the treatment of this disease. Second, malariotherapy causes iatrogenic morbidity and carries a direct risk for death from complications of P. vivax infection (8) or from coinfection with other, undetected, bloodborne pathogens. Third, a small but finite risk exists of local transmission of malaria when parasitemic persons enter the United States (10). Iatrogenic malaria cases should be reported promptly to local and state public health agencies.

References

1. Steere AC. Lyme disease. N Engl J Med 1989;321:586-96.

2. Miller GL, Craven RB, Bailey RE, Tsai TF. The epidemiology of

Lyme disease in the United States 1987-1988. Laboratory Medicine 1990;21:285-9.

3. Luft BJ, Dattwyler RJ. Treatment of Lyme borreliosis. Rheum Dis Clin North Am 1989;15:747-55.

4. Logigian EL, Kaplan RF, Steere AC. Chronic neurologic manifestations of Lyme disease. N Engl J Med 1990;323:1438-44.

5. Preac-Mursic V, Weber K, Pfister HW, et al. Survival of Borrelia burgdorferi in antibiotically treated patients with Lyme borreliosis. Infection 1989;17:355-9.

6. Dattwyler RJ, Luft BJ. Immunodiagnosis of Lyme borreliosis. Rheum Dis Clin North Am 1989;15:727-34.

7. Heimlich HJ. Should we try malariotherapy for Lyme disease? (Letter). N Engl J Med 1990;322:1234-5.

8. Becker FT. Induced malaria as a therapeutic agent. In: Boyd MF, ed. Malariology. Philadelphia: WB Saunders, 1949:1145-57.

9. Mayne B. A review of selected papers contributing to the progress of malaria therapy during the past year. Southern Med J 1936;29:755-7. 10. Maldonado YA, Nahlen BL, Roberto RR, et al. Transmission of Plasmodium vivax malaria in San Diego County, California, 1986. Am J Trop Med Hyg 1990;42:3-9.

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