Malaria is a mosquito-borne blood disease transmitted by the bite of an infected female anopheles mosquito. Plasmodium falciparum is the commonest and is associated with significant morbidity and mortality.
The other species are P. malariae, P. vivax, P. ovale.
Signs and Symptoms
Classically, malaria presents with paroxysms of fever, chills, rigours, and sweating.
Other features include malaise, headache, myalgia, joint pains, refusal to feed, nausea, vomiting, abdominal discomfort, and diarrhoea.
Severe malaria presents with a combination of most of the above plus either one or more of the following:
- Parasitaemia >5% or >200,000 parasites per µl of blood in high transmission area or >100,000 parasites per µl of blood in the low transmission area.
- Anaemia Hb <5gm%
- Cerebral malaria manifesting as confusion, stupor, convulsions or coma
- Hyperpyrexia, temperature >39oC
- Hypoglycaemia (blood sugar <2.2mmol/L)
- Pulmonary oedema
- Disseminated intravascular coagulopathy (DIC – spontaneous bleeding)
- Malaria haemoglobinuria (Coca-cola coloured urine)
- Hypovolaemic shock
- Fluid electrolyte imbalance
In outpatient department cases
• Thick blood smear for malaria parasites (several slides may need to be done)
In inpatient cases
• Thin blood smear for parasite count, species identification, and RBC morphology:
Blood sugar levels,
A negative slide does not necessarily rule out malaria. Where cerebral malaria is suspected, begin appropriate therapy promptly.
Exclude other diseases, e.g., meningitis, which may present with similar features. It is recommended that you do not assume a positive slide explains the cause of a febrile illness: 20–30% of the normal population in endemic parts will have a positive slide for malaria parasites without symptoms and signs of malaria.
Treatment of malaria
These cases are treated as outpatients.
The current recommended treatment of patients with uncomplicated malaria is a combination of artemether-lumefantrine. This is available as a fixed-dose combination with a tablet containing 20mg of artemether and 120mg of lumefantrine. Treat adults with a 6-dose regimen of 4 tablets STAT, then 4 on hours 8, 24, 36, 48, and 60.
Should the patient deteriorate clinically at any time or symptoms persist 3–14 days after initiation of treatment, this should be considered as treatment failure. Treat such patients with quinine. Tablets come in 200mg or 300mg preparations. The dose is approximately 10mg/kg of body weight 8 hourly for 7 days.
Recommended second line drugs are dihydroartemisinin plus piperaquine.
Prompt diagnosis and management of the specific complication are vital. Quinine is the recommended treatment for severe malaria.
Give quinine injection as a loading dose of 20mg/kg IM then continue with a maintenance dose of 10mg/kg 8 hourly.
OR Give artemether as loading dose 3.2mg/kg IM injection, then 1.6mg/kg maintenance dose until the patient can take oral therapy, then put on a full course of AL
Reduce the temperature if hyperpyrexia if present and maintain fluid and electrolyte balance especially if there has been a significant fluid loss.
Monitor output. Output should be at least 30ml per hour. if hydration is inadequate and oliguria persists give frusemide 40–80mg IV STAT.
To manage convulsions: Use diazepam 0.3mg/kg IV/IM OR Rectal 0.5mg/kg OR Paraldehyde 0.2ml/kg IM.
In cases of hypoglycaemia, Monitor blood glucose regularly. Large doses of dextrose may be required 25% 2ml/kg or 50% 1ml/kg.
Anaemia: Monitor Hb regularly. Transfuse if Hb is less than 5g% AND patient develops cardiorespiratory distress (grunting, nasal flaring, chest indrawing, heart failure).
Check blood slide for malaria parasites daily to confirm if parasitaemia is falling.
The management of adults with severe malaria must be appropriate to each complication that develops. Quinine is not contraindicated in pregnancy. Fluid and antimalaria drugs are given for children.
IV quinine should be given as follows:
First dose 20mg/kg in ½ litre of fluid in 5% dextrose given over 4 hours (max 1,200mg). Then give 10mg/kg in ½ litre of fluid over 4 hours (max 600mg) 8 hours after commencing the initial dose. Repeat 10mg/kg 8 hourly until the patient can take orally.
Change to oral AL full dose or oral quinine to complete 7 days of therapy. Assess fluid regularly, including urine output.
It is similar to that for children, with special attention to the complications. If the patient cannot be weighed, the loading dose should be 900mg, followed by 600mg 8 hourly.
Monitor for and correct hypoglycaemia with 50% dextrose (1ml/kg). NB: Each infusion of quinine should be given over 4 hours.
Use quinine IM if IV drip cannot be monitored or fail to get IV access. Quinine hydrochloride may be given IM in emergencies
The dose for adults above 60kg should not exceed 600mg. Quinine hydrochloride may be given IM in emergencies.
Oral quinine may be introduced intragastrically by NG tube in situations when parenteral quinine is not available.
Look out for renal failure.
Anti-malaria prophylaxis should be given to the following groups when going to malaria-prone areas. All non-immune visitors to malarious areas;
Long-term residence >4 weeks
Short-term residence <4 weeks
Patient with sickle cell disease and thalassaemia
Children with impaired immunity (e.g., HIV, leukaemia)
Patients with hyperimmune malaria syndrome, leukaemia or splenectomy
Pregnant women (minimum of 2 IPT doses a month apart)
Current recommended antimalarial prophylaxis for those at risk is mefloquine 250mg given weekly starting 2 weeks before travel to a malaria endemic area and continued for up to 4 weeks after return to a non malarious area.
Seek early treatment for fever.
Cover exposed skin in the evenings.
use long-lasting insecticide-treated nets (LLINs).
As a community, participate in indoor residual spraying (IRS) in epidemic-prone areas