Case Presentation: 52-year-old Caucasian male with no past medical history significant for history of hypertension and hyperlipidemia who presented to the hospital secondary to fever of 103 degrees and chills for 3 days. Patient reports that fever was sudden in onset and has been intermittent which breaks with sweating. His review of systems were positive for fever chills sweating and weakness. His review of systems were negative for any cough congestion, shortness of breath, headache, neck stiffness, abdominal pain, nausea, vomiting or diarrhea, any dysuria or flank pain or negative for any weight loss. On further examination the patient reported that he was allergic to sulfa drugs. His home medication included hydrochlorothiazide, Norvasc and simvastatin.Travel history obtained from patient revealed that he was a pilot and travelled frequently. His last travel was from Germany to USA as a passenger 4 to 5 days before hospitalization. He denied any smoking or alcohol usage.On examination the patient’s vital signs included a T-max of 102 °F, heart rate of 100, respiratory rate of 16 oxygen saturation of 100% room air his physical examination was unremarkable. His labs revealed a mild elevation of white count to 12,000 other than that his electrolytes were normal. His blood cultures did not show any growth for 48 hours his urine analysis and urine cultures did not show any growth, his chest x-ray did not show any acute cardiopulmonary findings. He was evaluated by infectious disease specialist. His fungal cultures did not show any growth. He had a lumbar puncture which did not show any organisms or any acute findings. His ANA and rheumatoid factors were negative ruling out autoimmune diseases.Patient continued to have persistent fever. His fever curves were plotted on a graph. History was obtained again. Based on his classic history of intermittent fevers with sweating and travel history labs of thick and thin smears were obtained which revealed malarial parasite.The patient was treated appropriately for his malaria and his fever improved.As malaria is very unusual in Germany the flight path in which the patient traveled was tracked. The patient’s flight started from an African country where Malaria was endemic and stopped in Germany prior to arriving in the US.It was concluded that the patient had disease transmission in the flight from female Anopheles mosquito’s bite.

Discussion: Malaria transmission from a mosquito bite is very rare in developed countries. This case reveals an unusual transmission of malaria in the flight which traveled from and Malaria endemic region and stopped in a developed country. The patient had a mosquito bite in the flight and developed malaria.

Conclusions: Obtaining a good travel history and social history and good examination and revisiting the patient’s history when fever of unknown origin is suspected can give us a definitive diagnosis.