1. Malaria
Definition: infection with protozoa, plasmodium vivax,
P. ovale, P. malaria, or P. falciparum.
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2. • Usually, people get malaria by being bitten by an infective female Anopheles mosquito. Only Anopheles
mosquitoes can transmit malaria and they must have been infected through a previous blood meal taken
from an infected person.

3.  Plasmodium life cycle
1. Sporozoites injected through human skin by female anopheline mosquito, then
migrate to liver.
2. In the hepatocytes, they multiply into merozoites. After 1-4 weeks incubation, the
hepatocytes rupture and the merozoites are released into the blood. P. vivax and P.
ovale can also become hypnozoites, incubating in liver for months or even years.
3. Enter RBCs and become trophozoites then schizonts, which form further
merozoites, leading to rupture and hence hemolysis and fever in 48-72 hr cycles.
Some merozoites become gametocytes, which are taken up in RBCs by
mosquitoes feeding on blood.
4. P. falciparum is the most pathogenic as it affects all RBC ages, including
reticulocytes, while others only affect mature RBCs.

4.  Tables diagram of malaria with its species and stages.

5.  Signs and symptoms
General:
1. Fever: all tertian (48-hourly) except quartan (72-hourly) in P. malaria. These classic
patterns aren't always clearly seen.
2. Rigors
3. Headache
4. Diarrhea and vomiting.
5. Hepatosplenomegaly
Falciparum malaria:
1. Flu-like prodrome: myalgia, malaise, headache, anorexia.
2. Irregular fever initially.
3. Jaundice
Complicated falciparum malaria:
1. Mortality approaches 100% if severe and untreated.
2. Cerebral malaria: altered mental status, seizures, coma, decerebrate posturing,
↑plantars, teeth-grinding.
3. AKI
4. Bleeding: hemoglobinuria ('blackwater fever'), DIC, retinal hemorrhages.
5. Metabolic: ↓glucose, metabolic acidosis, Kussmaul's breathing.
6. ARDS and pulmonary oedema.
7. Splenic rupture.
8. Shock

6.  Investigations
Diagnosis using blood films:
1. Serial testing: up to 3 times if 1st -ve.
2. Thick film – quick yes or no malaria – and thin film – which subtype.
3. Also shows parasitemia (%RBCs infected) and stage, with imminent decline in patient condition
due if there are ↑schizonts. Dangerous if parasitemia >2% and life-threatening if >5%.
4. Simple but less sensitive antigen detection kits are available too.
Bloods:
1. FBC: anemia, ↓platelets. Low platelets result from increased splenic activity during hemolysis,
leading to excess platelet clearance.
2. Coag: DIC.
3. ↓Glucose
4. ABG: metabolic acidosis.
U+E: AKI.
Other tests:
1. Urinalysis: blood.
2. Blood cultures to rule out bacterial sepsis.

7.  Management
Prophylaxis
Start 1 week before to check for side effects, and continue until 4 weeks after.
Areas without chloroquine resistant falciparum:
1. Chloroquine (daily) plus proguanil (weekly).
Areas with chloroquine resistance. Any 1 of:
1. Atovaquone/proguanil (Malarone). Few side effects, and is taken from 1 day before until 7
days afterwards. Expensive.
2. Doxycycline
3. Mefloquine (Lariam): once weekly.
Also:
1. Long sleeves dusk till dawn.
2. Mosquito nets
3. DEET repellent.

8.  Treatment
1. P. vivax, P. ovale, and P. malaria: chloroquine plus primaquine.
2. Uncomplicated P. falciparum: 1st-line artemether/lumefantrine (Riamet). 2nd-line:
quinine/doxycycline (quinine/clindamycin in kids), or atovaquone/proguanil.
3. Complicated P. falciparum (cerebral, renal, or shock): artesunate IV (preferably), or
quinine IV + doxycycline IV/PO. Careful monitoring of fluid, lactate, U+E. Transfuse if
anemic.

9.  Complications
1. P. vivax and P. ovale can remain dormant in the liver as hypnozoites and relapse years
later. Causes tropical splenomegaly syndrome if recurrent.
2. P. malaria can lie low in blood for years, with or without symptoms.
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