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37. Malaria: Mosquitos Suck!
Keywords
MalariaCerebral malariaThin smearThick smearMalaroneQuinidineSevere malariaComplicated malariaUncomplicated malariaFemale anophelesMalaria transmissionPlasmodium falciparum Periodic feverSeizures in cerebral malariaParasitemiaLumbar punctureCerebral malariaHead CTExchange transfusion in severe malariaAntiepilepticCase 1
“My child keeps having fevers and won’t eat!!”
Pertinent History
A 4-year-old girl presented to the emergency department (ED) due to fever and decreased appetite for 1 week. The child migrated to the USA from Burkina Faso 18 days ago. The parents reported intermittent shivering and vomiting and how on some days, she seemed fine without any symptoms. They also complained that she had been less active and playful. She had no past medical history.
Physical Exam
Vitals: Temperature 101.9 ° F; HR 132 bpm; BP 115/67 mmHg; RR 24; SPO2 99%
Constitutional: Ill but non-toxic in appearance
Hydration: Dry skin and mucous membranes
Eyes: Pale without conjunctival injection nor scleral icterus
Abdomen: Full and soft with splenomegaly; no hepatomegaly or abdominal tenderness
Skin: Warm and dry without rashes
ED Course
The patient was evaluated and laboratory work was ordered. The differential diagnosis included sepsis, malaria, viral infection, and typhoid fever. She received acetaminophen for her fevers. Due to a concern for dehydration, patient received a 20 cc/kg bolus of normal saline (NS) and was started on maintenance rate of D5W 0.45NS. The WBC was normal and cultures were pending. Antibiotics were not initiated due to low concern for sepsis. She was admitted for further management of malaria.
Pertinent Laboratory Findings
Preliminary blood smear: Malaria parasite on thick smear. Thin smear pending.
Test | Result | Units | Normal Range |
|---|---|---|---|
WBC | 8.2 | K/uL | 3.8–11.0 103/mm3 |
Hgb | 8.2 | g/dL | (Male) 14–18 g/dL (Female) 11–16 g/dL |
Platelets | 146 | K/uL | 140–450 K/uL |
Case 2: Severe Malaria
Pertinent History
A 14-year-old male presented to the ED with vomiting, headache, stomach pain, and subjective fevers. Symptoms started 4 days ago with frontal, non-radiating headaches without associated photo- or phono-phobia. He was evaluated in the ED 2 days ago and was tested and treated for a Streptococcal pharyngitis with 1.2 million units of IM penicillin G benzathine.
The patient’s symptoms progressively worsened over the next 2 days with persistent headaches, multiple non-bilious and non-bloody vomiting, epigastric pain, and episodes of chills and warmth without temperature checks at home. He had used acetaminophen and bismuth subsalicylate at home with minimal to no improvement. He had lived in Ivory Coast for the past year and arrived back in the USA 2 weeks ago to visit his parents.
Physical Exam
Vitals: Temperature 100.9 °F (38.3ºC); HR 100 bpm; RR 22; BP 106/52 mmHg; SpO2 96% RA
General Appearance: Ill-appearing, crying due to headaches
Eyes: Scleral icterus
Mouth: Dry cracked lips and tacky mucous membranes
Neck: Normal and full range of motion with no meningismus
Abdominal: Flat with mild epigastric tenderness
Neurological: Crying in discomfort but alert and oriented to place, person and time, GSC 15, negative Kernig’s and Brudzinski signs
Significant Laboratory Findings
Test | Result | Units | Normal Range |
|---|---|---|---|
WBC | 3.3 | K/uL | 3.8–11.0 103/mm3 |
Hgb | 8.9 | g/dL | (Male) 14–18 g/dL (Female) 11–16 g/dL |
Platelets | 43 | K/uL | 140–450 K/uL |
Total Bilirubin/Direct Bilirubin | 6.7/3.8 | mg/dL | 0.2–1.4 mg/dL/0.0–0.4 mg/dL |
Albumin | 2.9 | g/dL | 3.5–5.0 gm/dL |
Preliminary blood smear: Positive for malaria parasite
ED Course
The patient received acetaminophen while in triage. During further evaluation, the patient was noted to feel hotter, sleepier, and more ill.
Repeat Vitals: Temperature 103.2F (39.6ºC); HR 130 bpm; BP 82/44 mmHg.
Due to a concern that the patient may be decompensating and might be septic, an IV line was established, labs were drawn, and 2 boluses of 20 cc/kg NS were given. At the same time, IV Vancomycin and Ceftriaxone were started. Vitals improved to BP 111/65 mmHg and HR 105 bpm, but the patient remained somnolent. With preliminary smear report of malaria parasite and labs significant for anemia and thrombocytopenia, patient was also started on IV quinidine, and clindamycin. EKG was performed prior to IV quinidine which showed NSR and a QTc of 390 ms. Patient was then transferred to PICU for continued management for severe malaria.
Learning Points: Malaria in Children
Priming Questions
What are the different manifestations of malaria in children?
How is severe malaria diagnosed?
When should the treatment for malaria start and what adjunct treatments must be considered in the ED?
Introduction
- 1.
Malaria is a parasitic mosquito-borne infection of red blood cells. The word “malaria” translated from Italian is “bad air:” From mala “bad” + aria “air.”
- 2.
It is estimated that nearly 300,000 children under the age of 5 died of malaria in 2016, equivalent to nearly 800 young lives lost each day. Most of these deaths occur in the WHO African region (92%), South-East Asian region (6%), and the WHO Eastern Mediterranean region (2%) [1].
- 3.
Although previously uncommon in the USA, malaria cases are increasing due to immigrants and travel trends. According to CDC, 1517 confirmed malaria cases were reported in the USA in 2015 [2].
Areas Where Malaria is Endemic
Images Courtesy of Centers for Disease Control and Prevention
Pathology/Pathophysiology
- 1.
Malaria is transmitted through bites of carrier female anopheles mosquitos.
- 2.
People who did not travel to endemic regions may be exposed or infected if the mosquitoes traveled in the luggage to nonendemic areas [3–5].
- 3.
Other possible modes of transmission include blood transfusion [6], organ transplantation [7], and congenital transmission (mother to newborn) [8].
- 4.
Life cycle:
After a vector mosquito bites the host, malaria parasites (sporozoites) get into the bloodstream and reach the hepatocytes.
These sporozoites replicate in hepatocytes forming hepatic schizonts, which eventually rupture and release parasites into the bloodstream (merozoites).
Some sporozoites remain dormant in the liver in the form of hypnozoites, which might cause malaria relapse later. There forms are only seen in P. vivax and P. ovale.
Merozoites infect red blood cells and either undergo asexual multiplication forming erythrocyte schizonts or develop into sexual stage gametocytes.
Schizonts rupture releases the contents of merozoites to bloodstream, which infect other red blood cells. Schizonts are the cause of active disease.
Gametocytes circulate in blood until ingested by the vector anopheles mosquito biting the human host [9]
Malaria Life-Cycle
National Institutes of Health (NIH) Public Domain Image
- 5.
Species.
Different species of Plasmodium exist:
Plasmodium falciparum is the most common and pathogenic malaria species and is associated with severe illness and death, typically among children <5 years of age.
P. Falciparum | P. Vivax | P. Ovale | P. Malaria | P. Knowlesi (rarely affects humans) | |
|---|---|---|---|---|---|
Average Incubation [10] | 9–14 days | 12–17 days | 16–18 days | 18–40 days | 9–12 days [11] |
Erythrocyte cycle [12] | 48 hours | 48 hours | 48 hours | 72 hours | 24 hours |
Hypnozoites (liver forms) | Absent | Present | Present | Usually absent | Absent |
Severe Malaria | Yes, most common | Yes [13] | No | No | Yes [14] |
Relapse | No | Yes | Yes | No | No |
Special Features | Cerebral malaria | Splenic rupture | Least common | Mildest and most chronic | Nephrotic syndrome (steroid resistant) |
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