more than 200 million people are annually infected with malaria world - wide . in comparison , congenital malaria ( cm ) occurs very infrequently . since then , only about 300 cases have been reported in world literature so far . a 16-day - old male child was admitted with complains of refusal to feed and poor activity . the baby was delivered at the gestational age of 32 - 34 weeks , in the same hospital by cesarean section . activity , pulse , grimace , appearance , respiration score at 1 min and 5 min was 7/10 . he had been admitted on 1 day of life for low birth weight ( 1,500 g ) and poor activity . rooting and sucking the baby was treated with intravenous antibiotics and fluids for probable sepsis and was discharged after 4 days of admission on repeated requests of parents . the baby came in the out - patient department on 10 day of life for follow - up . the baby was still on spoon feeding and there was no weight gain ( weight = 1,480 g ) . in order to find the cause of failure to gain weight in the baby , admission of the baby hence , sepsis screen was performed on the out - patient basis and it came out to be negative . on present admission , except for mild tachycardia , vital signs were stable . on abdominal examination , hepatosplenomegaly was present . on 2 day of admission , the direct fraction of serum bilirubin ( t = 9.6 mg / dl , d = 4.6 mg / dl , i d = 5.0 mg / dl ) was elevated . sepsis screen ( total leukocyte count = 8500/mm , platelet count = 96300/mm , c - reactive protein = negative , band cells = 5% ) was again negative . the peripheral blood smear examination showed the presence of plasmodium vivax . a provisional diagnosis of cm was made . the mother then gave a history of fever with chills at third trimester of pregnancy , for which she was treated with some drugs . the baby was treated with oral chloroquine at the standard cumulative dose of 10 mg / kg given in divided doses over 3 days . after completion of the course of chloroquine , the baby showed marked improvement in activity . after 1 month of discharge , the baby had significant weight gain ( weight = 2,700 g ) , pallor subsided ( hemoglobin% ( hb% ) = 17.6 g / dl ) , spleen was not palpable and the baby was active and playful and was on a full breast feeds . cm increases the risk of neonatal mortality by increasing the risk of low birth weight , pre - mature labor , intrauterine growth retardation and still birth . fetal exposure to maternal blood containing infected red blood cells ( rbcs ) may be occur inutero or intrapartum . though , the infection is present from birth , the usual age of appearance of classic features is on the 10 - 20 day of life . the late appearance of symptoms is because of the protective maternal immunoglobulin g ( igg ) antibody transmitted to the baby and also due to low parasitemia in the early days of life . in the neonate as mature schizont ruptures , several merozoites are released , which infect other rbcs and this cycle continues ; thus increasing parasitemia gradually with days of life . the increased burden on spleen to clear the infected rbc leads to splenomegaly , jaundice and anemia ; the classic manifestations of cm . before this period , neonates of cm may manifest with non - specific features as refusal to feed and poor activity , like the presentation in the first two visits of our case . the review of previously reported cases of cm in preterm babies shows that cm may present at an earlier age in preterm babies . this can be due to the fact that the transmission of maternal protective igg antibody occurs very insignificantly in preterm babies . however in the present case , the neonate was preterm and low birth weight and presented without fever . review of the earlier reported cases of cm in preterm infants also shows the same trend . this can be explained by the well - known fact that the preterm and low birth weight babies are more prone to hypothermia rather than fever in conditions of infections . the absence of splenomegaly and normal peripheral blood smear examination in initial two visits in our patient may be due to low parasitemia in initial days of life . serological tests of higher sensitivity are needed for the early diagnosis of malaria especially , in stage of low parasitemia . the present case highlights that cm may present without fever in preterm and low birth weight babies . cm should be included in the differential diagnosis of such neonates who present with a constellation of symptoms of splenomegaly , jaundice and anemia even in the absence of fever . the present case also shows that cm may present with non - specific symptoms of lethargy and refusal to feed in initial few days of life .
congenital malaria ( cm ) is a rare disease with only about 300 cases reported so far . in general 
 , it presents with fever along with other common features such as jaundice , anemia and hepatosplenomegaly . 
 we report a case of cm who presented atypically without fever along with other typical features .