Malaria
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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
DDX
Fever in traveler
- Normal causes of acute fever!
- Malaria
- Dengue
- Leptospirosis
- Typhoid fever
- Typhus
- Viral hemorrhagic fevers
- Chikungunya
- Yellow fever
- Rift valley fever
- Q fever
- Amebiasis
- Zika virus
Diagnosis
- High index of suspicion if fever + travel to endemic region
- See CDC list by country: [[1]]
- Symptoms
- Fever
- Cyclic only after chronic infection
- HA, cough, GI
- thrombocytopenia and splenomegaly common
- Fever
- check thick and thin smear initially and if neg, repeat in 12- 24 hrs
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
Treatment[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
- Atovaquone-proguanil or
- Arthemeter-lumefantrine or
- Quinine plus Tetracycline, doxycycline, or clindamycin
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
- Admission for
- Patients with suspected or confirmed P falciparum or P knowlesi infection
- Children
- Pregnant women
- Immunodeficient individuals
- 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
Source
- 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
- ↑ 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
- ↑ World Health Organization. Guidelines for the treatment of malaria. Second edition. Geneva: World Health Organization; 2009:1-194