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

Background Severe 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 challenges. This report documents a case of recrudescent severe malaria in a Taiwanese traveler, highlighting clinical complexities related to organ support and altered drug pharmacokinetics. Case presentation A previously healthy 66-year-old Taiwanese man developed fever, vomiting, diarrhea, 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 parasitemia (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 hemodialysis and plasma exchange as supportive therapies. Initial treatment achieved parasite clearance and clinical improvement. However, four weeks later, the patient experienced recrudescence with recurrent fever, anemia, and return of parasitemia. The therapeutic regimen was then revised to intravenous artesunate combined with doxycycline and clindamycin, followed by oral artemether-lumefantrine. This approach led to successful parasite clearance within two weeks and complete recovery, with no further recurrence observed during follow-up. Conclusions This case highlights that even with prompt, guideline-based therapy, severe P. falciparum malaria in non-immune individuals can relapse, especially when organ failure and interventions such as plasma exchange may alter drug efficacy. 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.