Abstract
Neonatal malaria is rare due to protective maternal immunity and breastfeeding, particularly in non-endemic areas of the globe. Plasmodium (P.) knowlesi is a zoonotic species mainly found in Southeast Asia, and very few cases have been reported worldwide in the pediatric population. We report the first documented case of congenital malaria in Bahrain due to Plasmodium knowlesi. A 26-day-old, Pakistani male infant presented with a one-day history of fever, jaundice, lethargy, and hepatosplenomegaly. Laboratory investigations revealed pancytopenia and elevated inflammatory markers. Despite negative rapid testing for malaria antigen, the peripheral blood smear confirmed the presence of P. knowlesi. The mother's malaria PCR and smear were negative. The infant also tested positive for cytomegalovirus with high blood and urine viral loads. He was treated with intravenous artesunate and ganciclovir, followed by oral valganciclovir. The case spotlights the importance of considering congenital malaria in neonates with nonspecific systemic symptoms, even in non-endemic areas. Blood smear remains essential for the diagnosis even when rapid tests are negative. Co-infection with malaria may occur, and it may complicate the clinical picture. Clinicians in malaria-free regions must be aware of imported infections due to rising global migration.