A 27 year old male, native of Angola, where he was diagnosed with malaria, presents in our emergency department with headache, fever and myalgias. A diagnosis of severe Plasmodium ovale malaria with probable persistent hepatic forms was confirmed. He was started on a quinine and doxycycline scheme, later changed to atovaquone/proguanil due to concerns for resistance. Primaquine therapy was also administered. Despite clinical improvement and persistent elimination of parasitemia the patient

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... oped significant antimalarial side effects. Severe malaria can be associated with hemodynamic instability and serious organ dysfunction and requires prompt intravenous therapy. Malaria relapses are common with ovale parasites, which have dormant liver stage. Atovaquone/proguanil use is limited in endemic countries due to cost and resistance but can be used in developed countries for treatment of blood parasites. Anti-relapse therapy with primaquine is required for hynozoite elimination. Most antimalarial drugs have serious adverse reactions that should be monitored cautiously.