Special situationsMalaria
Section snippets
Introduction and epidemiology
Despite effective treatments, malaria remains a leading cause of mortality worldwide, killing over 3,000 children every day.1 In parts of Africa, the average person will catch malaria four or more times a year, so the disease is much more common than influenza in the UK. It is a substantial cause of morbidity in returning travellers in the UK, with a case fatality rate of 7.4 per 1000.2, 3 There is around a 1:5 chance that a patient presenting recently returned from sub-Saharan Africa with a
Pathophysiology
Malaria is a disease caused by protozoal parasites of the genus Plasmodium. Five species of Plasmodium cause disease in humans (Table 1); falciparum malaria causes almost all the deaths. In humans it is transmitted by female Anopheles mosquitoes that bite typically after dark. Peak biting time in Africa is from midnight – in Asia and South America it can be earlier in the evening, which has implications for prevention.
The pathophysiology of disease is incompletely understood.5 The virulence of
Clinical manifestations of disease
Symptoms develop from around 6 days after an infected bite. Most falciparum infections present within 1 month, although this can be extended, especially in those on prophylaxis. Vivax, malariae and ovale infection commonly have a longer incubation period (six months to several years have been reported) and vivax and ovale can relapse after an extended period because of persistence of hepatic hypnozoites. This is different from recrudescence where parasites reappear in the blood following
Diagnosis
Diagnostic delay, either because the patient has delayed presentation, or because a doctor has not suspected the diagnosis, is a key factor in mortality from malaria in non-endemic countries.8 Suspecting the diagnosis is paramount; do not be put off by a history of prophylaxis (malaria can occur even with perfect prophylaxis) or apparent localizing symptoms or signs (e.g. jaundice). Whilst malaria can exist with any symptoms, it is very rare for severe malaria to present in patients with a
General principles
Once malaria has been identified the key questions are: is this falciparum or non-falciparum and, if falciparum, is it severe (sometimes called complicated) or non-severe (Table 2)?
To admit or not to admit?
UK guidelines for treatment of malaria recommend that all patients with P. falciparum malaria be admitted to hospital for at least the first 24 hours, including those who do not initially meet criteria for severe disease.10 This is particularly important for children, pregnant women and the elderly, who are at
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The pathogenic basis of malaria
Nature
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Falciparum malaria as a cause of fever in adult travellers returning to the United Kingdom: observational study of risk by geographical area
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