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Approach Considerations
Failure to consider malaria in the differential diagnosis of a febrile illness in a patient
who has traveled to an area where malaria is endemic can result in significant
morbidity or mortality, especially in children and in pregnant or immunocompromised
patients.
Mixed infections involving more than 1 species of Plasmodium may occur in areas of
high endemicity and multiple circulating malarial species. In these cases, clinical
differentiation and decision making will be important; however, the clinician should
have a low threshold for including the possible presence of P falciparum in the
treatment considerations.
Occasionally, morphologic features do not permit distinction between P falciparum
and other Plasmodium species. In such cases, patients from a P falciparum
endemic area should be presumed to have P falciparum infection and should be
treated accordingly.
In patients from Southeast Asia, consider the possibility of P knowlesi infection. This
species frequently causes hyperparasitemia and the infection tends to be more
severe than infections with other non P falciparum plasmodia. It should be treated
as P falciparum infection.
P falciparum is resistant to chloroquine treatment except in Haiti, the Dominican
Republic, parts of Central America, and parts of the Middle East. Resistance is rare in
P vivax infection, and P ovale and P malariae remain sensitive to chloroquine.
Primaquine is required in the treatment of P ovale and P vivax infection in order to
eliminate the hypnozoites (liver phase).
In the United States, patients with P falciparum infection are often treated on an
inpatient basis in order to observe for complications attributable to either the illness or
its treatment.
Pregnancy
Pregnant women, especially primigravid women, are up to 10 times more likely to
contract malaria than nongravid women. Gravid women who contract malaria also have
a greater tendency to develop severe malaria. Unlike malarial infection in nongravid
individuals, pregnant women with P vivax are at high risk for severe malaria, and
those with P falciparum have a greatly increased predisposition for severe malaria as
well.
For these reasons, it is especially important that nonimmune pregnant women in
endemic areas use the proper pharmacologic and nonpharmacologic prophylaxis.
If a pregnant woman becomes infected, she should know that many of the antimalarial
and antiprotozoal drugs used to treat malaria are safe for use during pregnancy for
the mother and the fetus. Therefore, the medications should be used, since the
benefits of these drugs greatly outweigh the risks associated with leaving the infection
untreated.
Pediatrics
In children, malaria has a shorter course, often rapidly progressing to severe malaria.
Children are more likely to present with hypoglycemia, seizures, severe anemia, and
sudden death, but they are much less likely to develop renal failure, pulmonary
edema, or jaundice.
Cerebral malaria results in neurologic sequelae in 9-26% of children, but of these
sequelae, approximately one half completely resolve with time.
Most antimalarial drugs are very effective and safe in children, provided that the
proper dosage is administered. Children commonly recover from malaria, even
severe malaria, much faster than adults.
Monitoring
Patients with non P falciparum malaria who are well can usually be treated on an
outpatient basis. Obtain blood smears every day to demonstrate response to
treatment. The sexual stage of the protozoan, the gametocyte, does not respond to
most standard medications (eg, chloroquine, quinine), but gametocytes eventually die
and do not pose a threat to the individual's health.
Pharmacologic Therapy
IV preparations of antimalarials are available for the treatment of severe complicated
malaria, including artesunate and quinidine gluconate, which is used as a substitute for
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Inpatient Care
Patients with elevated parasitemia (>5% of RBCs infected), CNS infection, or
otherwise severe symptoms and those with P falciparum infection should be
considered for inpatient treatment to ensure that medicines are tolerated.
Obtain blood smears every day to demonstrate a response to treatment. The sexual
stage of the protozoan, the gametocyte, does not respond to most standard
medications (eg, chloroquine, quinine), but gametocytes eventually die and do not
pose a threat to the individual's health or cause any symptoms.
Consultations
Consider consulting an infectious disease specialist for assistance with malaria
diagnosis, treatment, and disease management. The CDC is an excellent resource if
no local resources are available. To obtain the latest recommendations for malaria
prophylaxis and treatment from the CDC, call the CDC Malaria Hotline at (770)
488-7788 or (855) 856-4713 (M-F, 9 am-5 pm, Eastern time). For emergency
consultation after hours, call (770) 488-7100 and ask to talk with a CDC Malaria
Branch clinician.[38]
Pregnant patients with malaria are at increased risk of morbidity and mortality.[39] In
addition, nonimmune mothers and immune primigravidas may be at an increased risk
of low birth weight, fetal loss, and prematurity. Consult an expert in malaria to
determine the safest and most effective prophylaxis or treatment in a pregnant
woman.
Medication
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