# Malaria Tropica: An Autopsy Case Report With a Discussion on the Presence of Malaria in Bulgaria

## TL;DR

This paper reports a case of fatal tropical malaria in Bulgaria and discusses the risk of malaria reintroduction in malaria-free regions due to climate change and migration.

## Contribution

The paper presents a detailed autopsy case of falciparum malaria in Bulgaria, highlighting the risk of reintroduction in non-endemic areas.

## Key findings

- The autopsy revealed gross and histopathological changes consistent with severe falciparum malaria.
- The case highlights the potential for malaria reintroduction in Bulgaria due to increased travel and climate change.
- Healthcare workers in malaria-free zones may be unprepared to manage imported malaria cases.

## Abstract

Malaria is an infectious disease caused by several types of parasitic plasmodia and transmitted to humans through Anopheles mosquitoes. The disease has long been widespread and has caused a significant number of deaths and decreased life quality from sequelae worldwide. As understanding of the disease increased immensely at the beginning of the 20th century, eradication plans were implemented to decrease disease transmission. This led to the successful eradication of malaria across predominantly industrialized countries, with multiple geographic areas remaining malaria endemic zones to this day. With climate changes and migration, the risk of reintroduction of malaria to malaria-free zones has risen due to relatively easy travel to endemic zones and importation of cases. On the one hand, this is a significant public health risk and, on the other, a challenge to the medical system, as healthcare workers in malaria-free zones are often ill-prepared to recognize, diagnose, and treat malaria cases. Herein, we present an autopsy and histopathology case report of tropical (falciparum) malaria, complicated with blackwater fever (malignant malaria) with prevalent gross and histopathological changes, including hemomelanin deposition in the spline, liver, and bone marrow; visible parasitic forms in the remaining red blood cells; Durk's granulomas, sludge, and petechial hemorrhages in the central nervous system; and hemoglobin casts within the renal tubular structures. We also discuss the history and risk of reintroducing malaria into a malaria-free zone - Bulgaria.