Malaria: Difference between revisions
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==Background==
==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
*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
**''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
*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
*Chemoprophylaxsis does not guarantee protection
*CDC Malaria Hotline: 770-488-7788
*'''CDC Malaria Hotline''': 770-488-7788
*Malaria is a US nationally notifiable disease and all cases should be reported
*Malaria is a US nationally notifiable disease and all cases should be reported
*Malaria vaccine with ~30% efficacy will be piloted in African countries in 2018, study to assess pediatric mortality<ref>WHO. Ghana, Kenya and Malawi to take part in WHO malaria vaccine pilot programme. 24 April 2017. http://www.afro.who.int/en/media-centre/pressreleases/item/9533-ghana-kenya-and-malawi-to-take-part-in-who-malaria-vaccine-pilot-programme.html</ref>


===Traveler Precautions===
===Traveler Precautions===
The CDC recommends travelers to malaria-endemic regions take the following precautions:
The CDC recommends travelers to malaria-endemic regions take the following precautions:<ref>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</ref>
*Chemoprophylaxis
*Chemoprophylaxis
*Use of insecticide-treated bed nets
*Use of insecticide-treated bed nets
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*Wear long-sleeve shirts and pants
*Wear long-sleeve shirts and pants


==DDX==
==Clinical Features==
{{Template:Fever in Traveler DDX}}
*[[Fever]] + exposure to [http://wwwnc.cdc.gov/travel/destinations/list.htm endemic country]
 
**Cyclic fever only after chronic infection
==Diagnosis==
*Headache, cough, GI symptoms
*High index of suspicion if fever + travel to endemic region
**See CDC list by country: [[http://wwwnc.cdc.gov/travel/destinations/list.htm]]
*Symptoms
**Fever
***Cyclic only after chronic infection
** HA, cough, GI
**thrombocytopenia and splenomegaly common
*check thick and thin smear initially and if neg, repeat in 12- 24 hrs


===Classification===
===Classification===
'''Severe'''
'''Severe'''
Any one of the following:
*Any one of the following:
#AMS/coma
**[[Altered mental status]]/coma
#Severe normocytic anemia [hemoglobin < 7]
**Severe normocytic anemia [hemoglobin < 7]
#Renal failure
**Renal failure
#ARDS
**[[ARDS]]
#Hypotension
**[[Hypotension]]
#DIC
**[[DIC]]
#Spontaneous bleeding
**Spontaneous bleeding
#Acidosis
**Acidosis
#Hemoglobinuria
**Hemoglobinuria
#Jaundice
**[[Jaundice]]
#Repeated generalized seizures
**Hepatomegaly
#Parasitemia >5%
**Splenomegaly
**Repeated generalized [[seizures]]
**Parasitemia >5%
 
'''Uncomplicated'''
'''Uncomplicated'''
#None of the above
*None of the above


==Treatment<ref>World Health Organization. Guidelines for the treatment of malaria. Second edition. Geneva: World Health Organization; 2009:1-194</ref>==
==Differential Diagnosis==
#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)
{{Fever in Traveler DDX}}
#[[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)


==Evaluation==
*First smear positive in >90% of cases (thick and thin Giemsa stain)
**If initial negative, must be repeated BID x 2-3 days for proper exclusion of malaria
**Determines degree of parasitemia and type (e.g. ''P. falciparum'')
*Additional lab findings
**Normocytic [[anemia]]
**[[Thrombocytopenia]]
**↑ ESR
**↑ LDH
**LFT abnormalities
**↑ Cr
**[[Hyponatremia]]
**[[Hypoglycemia]]
**False positive VDRL


;For specific dosing see the [http://www.cdc.gov/malaria/resources/pdf/treatmenttable.pdf CDC Recommendations] or call the Malaria CDC Hotline(855) 856-4713
==Management==
*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'')<ref>World Health Organization. Guidelines for the treatment of malaria, 3rd ed, WHO, Geneva 2015. http://www.who.int/malaria/publications/atoz/9789241549127/en/</ref>
*[[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)


===Uncomplicated Malaria===
{{Malaria antibiotics}}
*Atovaquone-proguanil  or
*Arthemeter-lumefantrine or
*Quinine plus Tetracycline, doxycycline, or clindamycin
 
===Severe Malaria===
*Intravenous quinidine plus tetracycline, or doxycycline or clindamycin


===Cerebral Malaria===
===Cerebral Malaria===
*Insufficient evidence for or against giving antiepileptics
*Insufficient evidence for or against giving antiepileptics
*For severe cerebral edema, mannitol and steroids have not show a demonstrable benefit
*For severe cerebral edema, mannitol and steroids have not shown a demonstrable benefit


==Disposition==
==Disposition==
#Admission for:
===Admit for===
##Patients with suspected or confirmed P falciparum or P knowlesi infection
*Patients with suspected or confirmed ''P falciparum'' or ''P knowlesi'' infection
##Children
*Young children
##Pregnant women
*Pregnant women
##Immunodeficient individuals
*Immunocompromised patients
#ICU for:
 
##Severe complications (e.g.coagulopathy or end-organ failure)
===Admit to ICU for===
##Cerebral malaria (e.g. [[AMS]], repeated [[seizures]], coma)
*Severe complications (e.g.coagulopathy or end-organ failure)
##Parasitemia
*Cerebral malaria (e.g. [[altered mental status]], repeated [[seizures]], coma)
###>2% in pts non-immune (i.e. travelers)
*Parasitemia
###>5% in pts semi-immune (i.e. locals)
**>2% in non-immune (i.e. travelers)
**>5% in semi-immune (i.e. locals)


==See Also==
==See Also==
[[Travel Medicine]]
*[[Travel Medicine]]
*[[Parasitic Diseases]]
 
==External Links==
*[https://www.iamat.org/risks/malaria?gclid=CIDPmoaO7csCFZSGfgod24UAfQ IAMAT world map and country details ]


==Source==
==References==
*Mirzaian E, Durham MJ, Hess K, et al. Mosquito-borne illnesses in travelers: a review of risk and prevention. Pharmacotherapy. 2010;30(10):1031-1043
<references/>


[[Category:ID]]
[[Category:ID]]
[[Category:TropMed]]
[[Category:Tropical Medicine]]

Revision as of 22:51, 18 January 2019

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
  • Malaria vaccine with ~30% efficacy will be piloted in African countries in 2018, study to assess pediatric mortality[1]

Traveler Precautions

The CDC recommends travelers to malaria-endemic regions take the following precautions:[2]

  • 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

Uncomplicated

  • None of the above

Differential Diagnosis

Fever in traveler

Evaluation

  • First smear positive in >90% of cases (thick and thin Giemsa stain)
    • If initial negative, must be repeated BID x 2-3 days for proper exclusion of malaria
    • Determines degree of parasitemia and type (e.g. P. falciparum)
  • Additional lab findings

Management

  • 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)[3]
  • 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

  • Uncomplicated:
    • No evidence of organ dysfunction
    • Parasitemia <5%
    • Able to tolerate PO
  • Hospitalize:
    • Severe clinical manifestations in non-immune host for P. falciparum or P. knowlesi
  • Report to state health department
  • For non-pregnant patients (3 day course)
    • Artemether + lumefantrine
    • Artesunate + amodiaquine
    • Artesunate + mefloquine
    • Dihydroartemisinin + piperaquine
    • Artesunate + sulfadoxine–pyrimethamine (SP)
  • For pregnant (1st trimester)
  • Additional considerations
    • Avoid artesunate + SP in HIV/AIDS patients taking co-trimoxazole
    • Avoid artesunate + amodiaquine in HIV/AIDS patients taking efavirenz or zidovudine
    • P. vivax and P. ovale have dormant hypnozoites in the liver which require treatment with primaquine phosphate for complete eradication

Severe Malaria

  • Do not delay treatment in the unstable patient if strong suspicion for malaria as initial smear may be falsely negative
  • Treatment (IV for ≥24 hours then 3 days PO course)
    • Artesunate (IV)
      • Clears malaria faster than quinine
      • Distributed only through CDC
    • Quinidine (IV) also appropriate choice; more available in US

Cerebral Malaria

  • Insufficient evidence for or against giving antiepileptics
  • For severe cerebral edema, mannitol and steroids have not shown 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. altered mental status, repeated seizures, coma)
  • Parasitemia
    • >2% in non-immune (i.e. travelers)
    • >5% in semi-immune (i.e. locals)

See Also

External Links

References

  1. ↑ WHO. Ghana, Kenya and Malawi to take part in WHO malaria vaccine pilot programme. 24 April 2017. http://www.afro.who.int/en/media-centre/pressreleases/item/9533-ghana-kenya-and-malawi-to-take-part-in-who-malaria-vaccine-pilot-programme.html
  2. ↑ 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
  3. ↑ World Health Organization. Guidelines for the treatment of malaria, 3rd ed, WHO, Geneva 2015. http://www.who.int/malaria/publications/atoz/9789241549127/en/
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