eMedicine Specialties > Emergency Medicine > Infectious Diseases

Malaria: Follow-up

Author: Miguel C Fernández, MD, FAAEM, FACEP, FACMT, Associate Clinical Professor; Medical and Managing Director, South Texas Poison Center, Department of Surgery/Emergency Medicine and Toxicology, University of Texas Health Science Center at San Antonio
Contributor Information and Disclosures

Updated: May 29, 2009

Follow-up

Further Inpatient Care

• Perform thick and thin blood smears every 6-12 hours until parasitemia falls below 1% to ensure that the therapy instituted is clearing the infection.
• If parasitemia does not fall by 75% within 48 hours or if the blood is not cleared of parasites after 7 days, immediately initiate a different therapeutic regimen.
• Consult the CDC in all cases. Malaria infection may also be reportable to the local public health authority.

Further Outpatient Care

• Thick and thin blood smears should be obtained at least weekly for at least one month post treatment commencement to ensure clearance of parasitemia. 

Deterrence/Prevention

• Avoid endemic regions.
• Take the proper prophylactic drugs at proper intervals if traveling to endemic regions.
• Use topical insect repellent (30-35% diethyltoluamide [DEET]), especially from dusk to dawn.
• Wear long-sleeved permethrin-coated clothing if not allergic to permethrin; spray under beds, chairs, tables, and along walls.
• Sleep under fine-nylon netting impregnated with permethrin.
• Avoid wearing perfumes and colognes.
• Seek out medical attention immediately upon contracting any tropical fever or flulike illness.
• Chemoprophylaxis is available in many different forms.  
  • The drug of choice is determined by the destination of the traveler and any medical conditions the traveler may have that contraindicate the use of a specific drug.
  • Before traveling, people should consult their physician and consult the CDC's Malaria and Traveler's Web site to determine the most appropriate chemoprophylaxis.¹²  Travel Medicine clinics are also a useful source of information and advice. 

Complications

• Most complications are caused by P falciparum, and they may include the following:
  • Coma (cerebral malaria)
    • Defined as coma, altered mental status, or multiple seizures with P falciparum in the blood, cerebral malaria is the most common cause of death in patients with malaria. If untreated, this complication is lethal.
    • Even with treatment, 15% of children and 20% of adults who develop cerebral malaria die.
    • The symptoms of cerebral malaria are similar to those of toxic encephalopathy.
  • Seizures (secondary either to hypoglycemia or cerebral malaria)
  • Renal failure: As many as 30% of nonimmune adults infected with P falciparum suffer acute renal failure.
  • Hypoglycemia
  • Hemoglobinuria (blackwater fever)
    • Blackwater fever is the passage of dark urine, described as Madeira wine-colored.
    • Hemolysis, hemoglobinemia, and the subsequent hemoglobinuria and hemozoinuria cause this condition.
  • Noncardiogenic pulmonary edema: This affliction is most common in pregnant women and results in death in 80% of patients.
  • Profound hypoglycemia: Hypoglycemia often occurs in young children and pregnant women. It often is difficult to diagnose because adrenergic signs are not always present and because stupor already may have occurred in the patient.
  • Lactic acidosis: This occurs when the microvasculature becomes clogged with P falciparum. If the venous lactate level reaches 45 mg/dL, a poor prognosis is very likely.
  • Hemolysis resulting in severe anemia and jaundice
  • Bleeding (coagulopathy)

Prognosis

• Most patients with uncomplicated malaria exhibit marked improvement within 48 hours after the initiation of treatment and are fever free after 96 hours.
• P falciparum infection carries a poor prognosis with a high mortality rate if untreated. However, if diagnosed early and treated appropriately, the prognosis is excellent.

Patient Education

• For excellent patient education resources, visit eMedicine's Blood and Lymphatic System Center. Also, see eMedicine's patient education article Malaria.

Miscellaneous

Medicolegal Pitfalls

• The emergency physician should have a high index of suspicion if a history of fever is accompanied by suggestive symptoms in a patient with a history of travel to an endemic region.
  • Failure to consider malaria in the differential of a febrile illness following such travel, even if seemingly temporally remote, can result in significant morbidity or mortality, especially in children and pregnant or immunocompromised patients.
  • Mixed infections involving more than one 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 treatment for P falciparum to avoid potentially incompletely or inadequately treating this more dangerous species. 
  • Failure to recognize cases for which, due to their relatively high complication and fatality rate, inpatient treatment is highly recommended, particularly those caused by P falciparum and P knowlesi. 
  • Importantly, although rare, malaria infection should be considered in patients with no history of travel who have otherwise unexplained fever, anemia, CNS dysfunction, or sepsis.
  • Individuals traveling to malarial regions must be provided with adequate information regarding prevention strategies, as well as tailored and effective antiprotozoal medications.

Special Concerns

• 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 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 both the mother and the fetus. Therefore, they should be used, since the benefits of these drugs much outweigh the risks associated with leaving the infection untreated.
  • To obtain the latest CDC recommendations for malaria prophylaxis and treatment, call the CDC Malaria Hotline at (770) 488-7788 (M-F, 8 am-4:30 pm, Eastern Time). For emergency consultation after hours, call (770) 488-7100 and request to speak with a CDC Malaria Branch clinician.
• 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.

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