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Malaria

Malaria is caused by parasites that are transmitted to


people through the bites of infected female mosquitoes,
Anopheles mosquitoes. P. falciparum is the most deadly malaria
parasite and the most prevalent in Africa, where malaria cases
and deaths are heavily concentrated. The first symptoms of
malaria fever, headache, chills and vomiting usually appear
between 10 and 15 days after the mosquito bite. Without
prompt treatment, P. falciparum malaria can progress to severe
illness and death.
Symptoms of malaria

Symptoms of malaria can develop as quickly as seven days after you're bitten
by an infected mosquito.
Typically, the time between being infected and when symptoms start
(incubation period) is 7 to 18 days, depending on the specific parasite you're
infected with. However, in some cases it can take up to a year for symptoms
to develop.

The initial symptoms of malaria are flu-like and include:

a high temperature (fever)

headache

sweats

chills

vomiting

These symptoms are often mild and can sometimes be difficult to identify
as malaria.
With some types of malaria, the fever occurs in 48-hour cycles. During these
cycles, you feel cold at first with shivering. You then develop a fever,
accompanied by severe sweating and fatigue. These symptoms usually last
between 6 and 12 hours.

Other symptoms of malaria can include:

muscle pains

diarrhoea

generally feeling unwell

The most serious type of malaria is caused by the Plasmodium falciparum


parasite. Without prompt treatment, this type could lead to you quickly
developing severe and life-threatening complications, such as breathing
problems and organ failure.
Physical Examination
Most patients with malaria have no specific physical findings,
but splenomegaly may be present. Symptoms of malarial
infection are nonspecific and may manifest as a flulike illness
with fever, headache, malaise, fatigue, and muscle aches. Some
patients with malaria present with diarrhea and other
gastrointestinal (GI) symptoms. Immune individuals may be
completely asymptomatic or may present with mild anemia.
Nonimmune patients may quickly become very ill.
Severe malaria primarily involves P falciparum infection,
although death due to splenic rupture has been reported in
patients with non P falciparum malaria. Severe malaria
manifests as cerebral malaria, severe anemia, respiratory
symptoms, and renal failure.
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.
Diagnosis
The patient history should include inquiries into the following:

Recent or remote travel to an endemic area

Immune status, age, and pregnancy status

Allergies or other medical conditions

Medications currently being taken

The following blood studies should be ordered:

Blood culture

Hemoglobin concentration

Platelet count
Liver function

Renal function

Electrolyte concentrations (especially sodium)

Monitoring of parameters suggestive of hemolysis


(haptoglobin, lactic dehydrogenase [LDH], reticulocyte
count)

In select cases, rapid HIV testing

White blood cell count: Fewer than 5% of malaria patients


have leukocytosis; thus, if leukocytosis is present, the
differential diagnosis should be broadened

If the patient is to be treated with primaquine, glucose-6-


phosphate dehydrogenase (G6PD) level

If the patient has cerebral malaria, glucose level to rule out


hypoglycemia

The following imaging studies may be considered:

Chest radiography, if respiratory symptoms are present

Computed tomography of the head, if central nervous


system symptoms are present

Specific tests for malaria infection should be carried out, as


follows:

Microhematocrit centrifugation (sensitive but incapable of


speciation)

Fluorescent dyes/ultraviolet indicator tests (may not yield


speciation information)

Thin (qualitative) or thick (quantitative) blood smears


(standard): Note that 1 negative smear does not exclude
malaria as a diagnosis; several more smears should be
examined over a 36-hour period
Alternatives to blood smear testing (used if blood smear
expertise is insufficient): Include rapid diagnostic tests,
polymerase chain reaction assay, nucleic acid sequence-
based amplification, and quantitative buffy coat

Histologically, the various Plasmodium species causing malaria


may be distinguished by the following:

Presence of early forms in peripheral blood

Multiply infected red blood cells

Age of infected RBCs

Schffner dots

Other morphologic features

Patient

A 28,years old apparently healthy Indian female.


Two months post normal vaginal delivery, she came to
Saudi Arabia for Hajj on October 2011.
Two weeks later, she presented to a polyclinic with a 4
days history of intermittent fever and shortness of
breath. She took Paracetamol but the fever didnt
improve.
Today she comes to Thailand to see her husband who is
an infectious doctor. [Flight from India]
At Suvarnabhumi Airport, there are health control officers
screen for epidemic.
She is sick. She has high grade fever.

Physical examination
Vital signs : BT 40 degree Celsius, BP 120/80 mmHg, PR
90 bpm, RR 30 tpm
General appearance : An Indian female, looked fatigue,
rapid breathing
HEENT : moderate pale conjunctivae, mild icteric sclera
CVS&RS : normal
Abdomen : soft, tenderness at RUQ, no rebound
tenderness, hepatosplenomegaly
Extremities : muscle pain, no edema
Thick and thin blood films: Positive P. vivax
Rapid Antigen detection test: Positive P.vivax but
Negative P. falciparum
Antifalciparum antibodies: Negative

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