The selleck kinase inhibitor presence of infection for a minimum of at least 14 years in our now dialysis-dependent patient prior to diagnosis of nephrotic syndrome is consistent with this observation. The association between P malariae infection and nephrotic syndrome remains controversial. In fact, there has been little reported in the literature about quartan malarial nephrotic syndrome since the 1970s, which some speculate may be because of improved nutritional status and availability of antimalarials in endemic locations, although the validity of the originally proposed theory of immune complex deposition as the cause of quartan malarial nephrotic syndrome is in question.11 Although children from Nigeria

and the Ivory Coast exhibited membranous glomerulopathy with focal and segmental glomerulosclerosis as in our patient, studies in Ugandan children with presumed quartan malarial nephrotic syndrome exhibited proliferative glomerulonephritis,11 a difference that is not explained by the immune complex theory. More recently, among 272 children in Nigeria with nephrotic syndrome prospectively followed over 12 years, only 38.7% had concomitantly detected anti-CTLA-4 antibody inhibitor P malariae infection.12 Additionally, subsequent immunofluorescent examination of glomeruli from 76 cases of nephrotic syndrome in Nigeria detected P malariae antigens in only

25% of cases compared to hepatitis B in 24% of cases.13 In more recent reports, the prevalence of P malariae-associated nephrotic syndrome has declined in children and idiopathic nephrotic syndromes and those associated with sickle cell disease and HIV now occur more commonly.14,15 However, demonstrated difficulty in detecting sub-clinical P malariae through conventional means such as microscopic examination of the peripheral blood and antigen capture assays necessitates further studies with newer technologies like PCR to detect low-level parasitemia, as current infection rates among patients with

nephrotic syndrome may be underestimated. This case illustrates the importance of obtaining a detailed travel history, which should not be limited to recent travel. Increased ease of travel and consequent increased movement of people from areas where chronic infectious diseases are endemic to locations where such diseases are unknown and for which health care providers HSP90 have limited or no experience necessitates increased emphasis on global health in medical education. Meeting the health care needs of world travelers will not only require better understanding of the clinical presentations for specific diseases but also the epidemiology and distribution of such diseases. Targeted laboratory screening of asymptomatic travelers for tropical disease has been shown to be of value in identifying clinically unapparent tropical infections in up to 25% of returning travelers when carried out by informed health care providers who obtain well-structured histories prior to testing.