2 and 22%) were VFRs and less than 5 years old. No patient died, which is in agreement with the previously described low mortality rate of approximately 1% to 2% or less.8,9,17 The main tool used for diagnosis was the thick and thin blood film smears, which led to diagnosis in 55 (95%) of the

58 samples examined. However, even when malaria is suspected, a diagnosis may be missed due to a lack of experienced laboratory support.23,30 PCR for Plasmodium was useful for the diagnosis or species identification in seven patients, who were mainly recent immigrants. Taking into account the retrospective nature of this analysis, the PCR for Plasmodium was not performed in all patients and so we cannot affirm that PCR is only useful Y-27632 research buy find more for recent immigrant cases. However, due to the suitability of PCR to detect submicroscopic parasitemia of 3–4 parasites/µL41,42 and in the determination of mixed infections,43,44 possibly its application may be more useful in recent immigrant patients. In our opinion, when an experienced microbiologist is not available, treatment should be started if there is a high clinical suspicion (ie, VFRs who present with fever and thrombocytopenia) after obtaining a blood sample to perform a deferred thick and thin

blood smear. If possible, perhaps a malaria rapid antigen detection test should be performed. Multiple treatment options were used, which underlines the fact that there has been a lack of uniform criteria for the treatment of malaria. Furthermore, the extraordinary growth of immigration in Madrid in the last few years has surprised the health services, particularly the emergency room department who did not have previous experience in this disease. We ever believe that this aspect reinforces the need for continuous medical education in travel-migration medicine in European hospitals. Due to the results of this study, a specific protocol and guideline has been elaborated in our center. The strength of our study lies in the comparative study between recent immigrants and immigrant travelers (VFRs) among

children with imported malaria. The limitations of our study are associated with its retrospective design and that it is limited to a single center, although perhaps the results may be applied to other areas with a high proportion of immigrants. In summary, the characteristics of pediatric patients with malaria in our series are similar to that of other countries with a high percentage of immigrants from sub-Saharan Africa. However, two clinical groups with a different behavior should be distinguished. VFRs are those with a higher risk of complicated malaria with higher parasitemia levels, with higher fever and greater thrombocytopenia at diagnosis who frequently lack adequate malaria chemoprophylaxis when visiting their friends and relatives in endemic countries.