eMedicine Specialties > Pediatrics: General Medicine > Parasitology
Malaria: Follow-up
Updated: Apr 28, 2009
Follow-up
Further Inpatient Care
- Malaria can be life threatening, and intensive care may be required. Indications for admission to ICU include the following:
- Suspicion of cerebral malaria (ie, seizures, prolonged postictal coma, repeated seizures)
- Complications of malaria (eg, bleeding, renal failure, pulmonary edema)
- Heavy parasitemia: Admit patients from nonmalarious areas to the ICU if more than 2% of erythrocytes have malaria parasites. Patients from an endemic area can tolerate higher levels, but patients should be admitted to the ICU if more than 5% of erythrocytes are parasitized.
- Proof of cure blood smear examination
- Blood smears should be repeated after 24-48 hours to ensure that the drug is effective. This is especially important with P falciparum.
- If parasites are not cleared in 48 hours, a change in drug is required.
- Exchange transfusion
- An exchange transfusion is valuable in a very sick child. It reduces parasite load rapidly, corrects any bleeding diatheses, and corrects anemia.
- Erythrocytapheresis, the use of cell separation techniques to remove only the erythrocytes, has been used successfully in adults. It removes the parasites and has the added advantage of hemodynamic stability.
- Radical cure
- This implies the destruction of the dormant forms in the liver.
- Primaquine is the only drug active against the hypnozoites in the hepatocytes.
Transfer
- If appropriate drugs and experience in treating malaria are not available, the patient may need urgent transfer to a referral hospital.
Deterrence/Prevention
- Measures to prevent mosquito bites are very important for people living in or traveling through a malarious area.
- In one study, the use of the RTS,S/AS02D vaccine had a promising safety profile and reduced malaria infections.3
- Chemoprophylaxis is never fully effective and is undermined by poor adherence and parasite resistance to almost all drugs. Therapy should be started a week before entering a malarious area and continued for 4 weeks after leaving it.
- Chloroquine is the most commonly used drug, at a dose of 5 mg/kg once a week; however, significant resistance to it is now present.
- Mefloquine (5 mg/kg once a week) is recommended in areas where chloroquine resistance is common.
- The CDC provides country-specific advice on malaria chemoprophylaxis.
- Infants younger than 6 weeks should not be administered chemoprophylaxis.
- Prevention of mosquito bites is the most effective means of individual malaria protection.
- Cover the body while outdoors. Wear full-length sleeves and trousers. Clothes can also be treated with an insecticide, such as permethrin, which is safe for this purpose. Diethyl-m-toluamide (DEET) is an effective mosquito repellent when applied on the skin.
- Increased precautions are needed during the night because Anopheles species are nocturnal in habit. Sleeping under insecticide treated (permethrin 0.2 g/m2 of material every 6 mo) mosquito nets is perhaps the most beneficial antimalarial measure available. Bedrooms should be sprayed with an aerosol insecticide at dusk.
- A vaccine for malaria would be a major medical advance, but it is proving elusive. Vaccines against various malarial antigens have been tried for many years, all around the world. Unfortunately, the immunity provided is inadequate and short lived. A vaccine with a good rate and duration of protection will not be available for some years yet.
Complications
- Cerebral malaria: P falciparum causes sequestration of erythrocytes in the microvasculature of the brain (and other organs). Seizures and coma are common in a child with malaria, and prolonged postictal state should raise suspicion of this dangerous entity. Cerebral malaria can be rapidly fatal, and trying drugs to which resistance is common is dangerous. Prompt diagnosis and immediate treatment with a drug known to be effective in the area where the malaria was acquired can be lifesaving. The presentation is varied and may suggest other conditions, such as meningitis, encephalitis, or epilepsy. Thus, cerebral malaria should be considered in the differential diagnosis of a febrile neurological illness if a history of residence or travel through a malarious area exists.
- Bleeding tendency: A nonimmune child with heavy parasitemia sometimes develops generalized bleeding. Such bleeding is usually due to disseminated intravascular coagulation and is sometimes associated with a bacterial infection.
- Hemolysis: Some degree of hemolysis is part of malaria, but some children have excessive hemolysis, putting them at risk for renal failure. This hemolysis may be related to glucose-6-phosphatase dehydrogenase (G-6-PD) deficiency or an antibody-mediated destruction of erythrocytes.
- Anemia: Anemia is a faithful companion of malaria. Some children have anemia far exceeding that attributable to erythrocyte destruction by the malaria parasite. Other mechanisms of anemia are dyserythropoiesis, hypersplenism, shortened erythrocyte survival, and bone marrow suppression.
- Hypoglycemia: The malarial parasites consume glucose voraciously. Heavy parasitemia can result in hypoglycemia, which may be compounded by quinine and quinidine therapy. Hypoglycemia can be difficult to differentiate from cerebral malaria.
- Acute renal failure: Blackwater fever is a condition of hemolysis and acute renal failure. It is rarely observed now, being more common when quinine was used for prophylaxis.
- Pulmonary edema
- Hyperpyrexia
- Circulatory collapse (algid malaria)
- Jaundice
Prognosis
- Uncomplicated malaria due to P vivax, P malariae, and P ovale has an excellent prognosis. Most patients have a full recovery with no sequelae.
- Malaria due to P falciparum is dangerous. If not treated quickly and completely, complicated and severe malaria can result, which carries a grave prognosis.
- Malaria in children younger than 5 years carries the worst prognosis in endemic areas. In a nonimmune population, malaria is equally deadly at all ages.
- Cerebral malaria has a mortality rate of 25%, even with the best treatment. Survivors may have sequelae (eg, hemiparesis, cerebellar ataxia, aphasia, spasticity).
- Repeated attacks of malaria can lead to chronic anemia, malnutrition, and stunted growth.
Patient Education
- Advise persons visiting a malarious area regarding chemoprophylaxis and the need to continue the regimen for some weeks after leaving the area.
- Motivate travelers regarding chemoprophylaxis.
- Fewer than 20% of people diagnosed with imported malaria in the United States have taken recommended prophylaxis; more than 50% have taken no chemoprophylaxis at all.
- Recommend mosquito bite avoidance measures (ie, mosquito nets with insecticides, mosquito coils, and appropriate clothing).
- Advise persons visiting a malarious area regarding treatment of malaria and provide them doses of appropriate medicines to be started if attendance at a hospital is not immediately possible.
- For excellent patient education resources, visit eMedicine's Blood and Lymphatic System Center. Also, see eMedicine's patient education article Malaria.
Miscellaneous
Special Concerns
Malaria can be severe in pregnancy. This is a major problem because many antimalarial drugs are considered unsafe during pregnancy.
More on Malaria |
| Overview: Malaria |
| Differential Diagnoses & Workup: Malaria |
| Treatment & Medication: Malaria |
 Follow-up: Malaria |
| Multimedia: Malaria |
| References |
| « Previous Page | Next Page » |
References
World Health Organization. WHO Fact Sheet on Malaria. Fact Sheet No 94. World Health Organization. Available at http://www.who.int/mediacentre/factsheets/fs094/en/print.html. Accessed June 29, 2007.
Griffith KS, Lewis LS, Mali S, Parise ME. Treatment of malaria in the United States: a systematic review. JAMA. May 23 2007;297(20):2264-77. [Medline]. [Full Text].
[Best Evidence] Abdulla S, Oberholzer R, Juma O, et al. Safety and immunogenicity of RTS,S/AS02D malaria vaccine in infants. N Engl J Med. Dec 11 2008;359(24):2533-44. [Medline].
Eliades MJ, Shah S, Nguyen-Dinh P, et al. Malaria surveillance--United States, 2003. MMWR Surveill Summ. Jun 3 2005;54(2):25-40. [Medline]. [Full Text].
Emanuel B, Aronson N, Shulman S. Malaria in children in Chicago. Pediatr. 1993;92:83-85. [Medline].
Okie S. Betting on a malaria vaccine. N Engl J Med. Nov 3 2005;353(18):1877-81. [Medline]. [Full Text].
Thapa BR, Marwaha RK, Walia BN, et al. Falciparum malaria. Indian Pediatr. Mar 1987;24(3):221-5. [Medline].
Tracy JW, Webster LT. Malaria. In: Goodman and Gilman's The Pharmacological Basis of Therapeutics. 9th ed. New York, NY: McGraw Hill; 1996:965-985.
Warrell DA. Treatment and prevention of malaria. In: Bruce-Chwatt's Essential Malariology. 3rd ed. London, England: Edward Arnold; 1993:164-95.
Warrell DA. Clinical features of malaria. In: Bruce-Chwatt's essential malariology. 3rd ed. London, England: Edward Arnold; 1993:35-49.
Woodrow CJ, Haynes RK, Krishna S. Artemisinins. Postgrad Med J. Feb 2005;81(952):71-8. [Medline]. [Full Text].
Further Reading
Keywords
malaria, ague, mosquito, Plasmodium vivax, P vivax, Plasmodium ovale, P ovale, Plasmodium malariae, P malariae, Plasmodium falciparum, P falciparum, Anopheles mosquito, malarial fever, quartan malaria, tertian malaria, algid malaria
