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Background  Transfusion-transmitted malaria (TTM) is a well-recognized risk of receiving blood transfusions, and has occurred with  Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale , and  Plasmodium malariae.  The simian parasite  Plasmodium knowlesi  is also known to be transmissible through inoculation of infected blood, and this species is now the most common cause of malaria in Malaysia with a high rate of severity and fatal cases reported. No confirmed case of accidental transfusion-transmitted  P. knowlesi  has yet been reported.    Case presentation  A 23-year old splenectomized patient with beta thalassaemia major presented with fever 11 days after receiving a blood transfusion from a pre-symptomatic donor who presented with knowlesi malaria 12 days following blood donation. The infection resulted in severe disease in the recipient, with a parasite count of 84,000/µL and associated metabolic acidosis and multi-organ failure. She was treated with intravenous artesunate and made a good recovery. Sequencing of a highly diverse 649-base pair fragment of the  P. knowlesi  bifunctional dihydrofolate reductase-thymidylate synthase gene ( pkdhfr ) revealed that the recipient and donor shared the same haplotype.    Conclusions  This case demonstrates that acquisition of  P. knowlesi  from blood transfusion can occur, and that clinical consequences can be severe. Furthermore, this case raises the possibility that thalassaemic patients, particularly those who are splenectomized, may represent a high-risk group for TTM and severe malaria. With rising  P. knowlesi  incidence, further studies in Sabah are required to determine the risk of TTM in order to guide screening strategies for blood transfusion services.

Transfusion-transmitted severe Plasmodium knowlesi malaria in a splenectomized patient with beta-thalassaemia major in Sabah, Malaysia: a case report