title: Failure of atovaquone-proguanil malaria chemoprophylaxis in a traveler to Ghana.
abstract: Clinical failure of Malarone™ chemoprophylaxis is extremely rare. We report a case of Plasmodium falciparum malaria in a returned traveler to Ghana who fully adhered to atovaquone-proguanil (Malarone™) chemoprophylaxis daily dosing, yet took the pills on an empty stomach. Screening of the P. falciparum isolate revealed triple codon mutation of Dhfr at positions 51, 59, and 108. Plasma drug levels of both atovaquone and proguanil revealed sub-therapeutic concentrations.
authors.affiliation: Tropical Disease Unit, Division of Infectious Diseases, University Health Network-Toronto General Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Public Health Ontario Laboratories, Public Health Ontario, Toronto, Canada. Electronic address: andrea.boggild@utoronto.ca.
authors.forename: Andrea K
authors.initials: AK
authors.lastname: Boggild
authors.affiliation: Public Health Ontario Laboratories, Public Health Ontario, Toronto, Canada.
authors.forename: Rachel
authors.initials: R
authors.lastname: Lau
authors.affiliation: The Centre for the Study of Complex Childhood Diseases, Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: Denis
authors.initials: D
authors.lastname: Reynaud
authors.affiliation: Tropical Disease Unit, Division of Infectious Diseases, University Health Network-Toronto General Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Sandra A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University of Toronto, Canada.
authors.forename: Kevin C
authors.initials: KC
authors.lastname: Kain
authors.affiliation: Humber River Hospital, North York, Canada.
authors.forename: Marvin
authors.initials: M
authors.lastname: Gerson
mesh_terms: D000328:Adult; D000962:Antimalarials / Q000008:administration & dosage* / Q000097:blood; D053626:Atovaquone / Q000008:administration & dosage* / Q000097:blood; D003062:Codon; D004338:Drug Combinations; D004351:Drug Resistance / Q000235:genetics; D005260:Female; D005869:Ghana; D006801:Humans; D016778:Malaria, Falciparum / Q000469:parasitology / Q000517:prevention & control*; D009154:Mutation; D010963:Plasmodium falciparum / Q000235:genetics; D020641:Polymorphism, Single Nucleotide; D002727:Proguanil / Q000008:administration & dosage* / Q000097:blood; D017422:Sequence Analysis, DNA; D013762:Tetrahydrofolate Dehydrogenase / Q000235:genetics; D014195:Travel; D017211:Treatment Failure
chemical_list: D000962:Antimalarials; D003062:Codon; D004338:Drug Combinations; C109496:atovaquone, proguanil drug combination; D013762:Tetrahydrofolate Dehydrogenase; D002727:Proguanil; D053626:Atovaquone
keywords: Drug resistance; Malabsorption; Malaria; Malarone; Plasmodium falciparum