Malaria

Background

  • Caused by parasitic protozoa species of the genus Plasmodium (P ovale, P vivax, P malariae, P knowlesi, and P falciparum) carried by the Anopheles mosquito
    • P falciparum most severe
  • Failure to consider for febrile illness following travel, even if seemingly temporally remote, can result in significant morbidity or mortality, especially in children and pregnant or immunocompromised patients
  • Chemoprophylaxsis does not guarantee protection
  • CDC Malaria Hotline: 770-488-7788
  • Malaria is a US nationally notifiable disease and all cases should be reported

Traveler Precautions

The CDC recommends travelers to malaria-endemic regions take the following precautions:[1]

  • Chemoprophylaxis
  • Use of insecticide-treated bed nets
  • Use of DEET-containing insect repellents
  • Wear long-sleeve shirts and pants

Clinical Features

  • Fever + exposure to endemic country
    • Cyclic fever only after chronic infection
  • Headache, cough, GI symptoms

Classification

Severe

  • Any one of the following:
    • AMS/coma
    • Severe normocytic anemia [hemoglobin < 7]
    • Renal failure
    • ARDS
    • Hypotension
    • DIC
    • Spontaneous bleeding
    • Acidosis
    • Hemoglobinuria
    • Jaundice
    • Repeated generalized seizures
    • Parasitemia >5%

Uncomplicated

  • None of the above

Differential Diagnosis

Fever in traveler

Diagnostic Evaluation

High index of suspicion if fever + travel to endemic region

  • Check thick and thin blood smear (if neg, repeat in 12- 24 hrs)
  • Thrombocytopenia and splenomegaly common

Management[2]

  • Mixed infections involving more than one species of Plasmodium may occur in areas of high endemicity (have a low threshold for including treatment for P falciparum)
  • Hyponatremia in the setting of hypovolemia does not require treatment beyond rehydration
  • Treat hypoglycemia
  • Check HIV status (coinfection can lead to worse clinical outcomes)
  • Exchange transfusion for patients with:
    • P falciparum malaria with a parasitemia greater than 10%
    • Life-threatening complications (ie, coma, respiratory failure, coagulopathy, fulminant kidney failure)
For specific dosing see the CDC Recommendations or call the Malaria CDC Hotline(855) 856-4713

Uncomplicated Malaria

Severe Malaria

  • Intravenous quinidine plus tetracycline, or doxycycline or clindamycin

Cerebral Malaria

  • Insufficient evidence for or against giving antiepileptics
  • For severe cerebral edema, mannitol and steroids have not show a demonstrable benefit

Disposition

  • Admit for:
    • Patients with suspected or confirmed P falciparum or P knowlesi infection
    • Young children
    • Pregnant women
    • Immunocompromised patients
  • Admit to ICU for:
    • Severe complications (e.g.coagulopathy or end-organ failure)
    • Cerebral malaria (e.g. AMS, repeated seizures, coma)
    • Parasitemia
      • >2% in pts non-immune (i.e. travelers)
      • >5% in pts semi-immune (i.e. locals)

See Also

References

  1. ↑ WHO Malaria Policy Advisory Committee and Secretariat. Malaria Policy Advisory Committee to the WHO: conlusionsions and recommendations of September 2013 meeting. Malar J. 2013;12(1):456
  2. ↑ World Health Organization. Guidelines for the treatment of malaria. Second edition. Geneva: World Health Organization; 2009:1-194
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