Autochthonous Plasmodium falciparum malaria in a high-altitude, non-endemic region of Ethiopia: a case report

Malaria transmission in Ethiopia is traditionally limited to altitudes below 2000 m. Debark Town, situated at 2850 m, is a high-altitude highland fringe area characterized by a cold climate and has historically been considered a non-endemic zone. This report describes a rare, locally acquired case of Plasmodium falciparum in this extreme environment. A 15-year-old Ethiopian female of Amhara ethnicity resident in Debark Town presented with a 5-day history of high-grade fever (39.5 °C), headache, and vomiting. Significantly, she reported no history of travel to known malaria-endemic regions. Clinical examination revealed tachycardia (140 bpm) and hypotension (90/50 mmHg). Laboratory investigations showed profound thrombocytopenia (20 × 10 9 /L). P. falciparum infection was confirmed via a rapid diagnostic test (RDT) and thick blood smear (0.14% parasitemia). Despite the hypotension and low platelet count, the patient remained alert and was classified as having high risk but uncomplicated malaria. The patient was treated with a weight-based, six-dose regimen of Artemether–Lumefantrine (ACT) and supportive fluid resuscitation. Rapid clinical response was observed; apyrexia was achieved within 24 h. A follow-up assessment at 1 week confirmed full clinical and hematological recovery with negative parasitology. This case highlights the shifting epidemiology of malaria in the Ethiopian highlands, where traditional "altitude barriers" may no longer provide absolute protection. Clinicians in high-altitude zones must maintain a high index of clinical suspicion for malaria in febrile patients, regardless of travel history, to ensure early diagnosis and prevent severe outcomes in non-immune populations.