Plasmodium vivax congenital and neonatal malaria with atypical presentation in Western Ethiopia: four cases highlighting diagnostic pitfalls

BACKGROUND: Congenital and neonatal malaria (CNM) is under-recognized in Ethiopia and often presents with features that mimic neonatal sepsis. Plasmodium falciparum remains the predominant cause of malaria both nationally and at our facility, while CNM due to Plasmodium vivax is uncommon. Nevertheless, clearer clinical descriptions are needed to support early recognition. The presence of P. vivax, historically neglected in malaria control programmes, introduces additional complexity in the recognition and management of CNM. METHODS: We conducted a descriptive case series of neonates admitted to the neonatal intensive care unit of Aira General Hospital, between June 2024 and September 2025. Clinical presentation, diagnostic workup, treatment, and outcomes were documented for neonates diagnosed with congenital or neonatal malaria. RESULTS: Four neonates were included two girls with a median age at presentation of 18 days (range 1-21). Fever and poor feeding were each seen in three infants, tachypnea in two; one was afebrile and presented with omphalitis. Two had thrombocytopenia and one anaemia. Plasmodium vivax was confirmed on Giemsa-stained thick/thin smears (parasitaemia + 1 in two cases, + 2 in one, and 3 in one). All received IV artesunate (3 mg/kg) plus empiric antibiotics and were discharged by hospital day 7; no deaths. Maternal malaria was documented in two pregnancies (one vivax, one falciparum), and one infant presented on day 1, consistent with congenital infection. Outpatient follow-up was recorded for one case. CONCLUSION: This case series underscores the clinical diversity and diagnostic challenges of P. vivax-associated congenital and neonatal malaria in Ethiopia. The findings highlight the need for heightened clinical suspicion in endemic regions, especially where neonatal sepsis is common. The rising incidence of P. vivax relative to P. falciparum calls for renewed attention from clinicians, researchers, and policymakers to strengthen diagnostic capacity, surveillance, and targeted interventions.