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What is Malaria?

Definition
  • A blood-borne infection with protozoan parasites of the genus Plasmodium, transmitted by the bite of infected Anopheles mosquitoes.
  • Malaria is caused by a parasite transmitted from one human to another via the bite of an infected Anopheles mosquito. The parasites migrate to the liver, mature, and enter the bloodstream, where they rupture red blood cells. An infected pregnant woman can transmit malaria to her unborn child.

What is Malaria?
  • Malaria is a disease caused by a parasite. The parasite is spread to humans through the bites of infected mosquitoes. People who have malaria usually feel very sick with a high fever and shaking chills.
Symptoms
Signs and symptoms of malaria may include:
  • Fever
  • Chills
  • A general feeling of discomfort
  • Headache
  • Nausea and vomiting
  • Diarrhea
  • Abdominal pain
  • Muscle or joint pain
  • Fatigue
  • Rapid breathing
  • Rapid heart rate
  • Cough
Malaria signs and symptoms typically begin within a few weeks after being bitten by an infected mosquito. However, some types of malaria parasites can lie dormant in your body for up to a year.

Causes
  • Malaria is caused by a single-celled parasite of the genus plasmodium. The parasite is transmitted to humans most commonly through mosquito bites.
Mosquito Transmission Cycle 
  1. Uninfected Mosquito: A mosquito becomes infected by feeding on a person who has malaria.
  2. Transmission of a parasite: If this mosquito bites you in the future, it can transmit malaria parasites to you.
  3. In the liver: Once the parasites enter your body, they travel to your liver — where some types can lie dormant for as long as a year.
  4. Into the bloodstream: When the parasites mature, they leave the liver and infect your red blood cells. This is when people typically develop malaria symptoms.
  5. On to the next person: If an uninfected mosquito bites you at this point in the cycle, it will become infected with your malaria parasites and can spread them to the other people it bites.

Other modes of Transmission
Because the parasites that cause malaria affect red blood cells, people can also catch malaria from exposure to infected blood, including: 
  1. From mother to unborn child
  2. Through blood transfusions
  3. By sharing needles used to inject drugs

Medical History
  • Mosquito bite
  • Transfusion of blood product
  • Solid-organ transplant
  • Shares needles
  • Travel

Findings
  • Coma
  • Focal neurological signs
  • Impaired cognition
  • Nuchal rigidity
  • Respiratory distress
  • Retina finding
  • Seizure - Acute
  • Splenomegaly
  • Delirium - Acute
  • Edema - Acute
  • Extreme exhaustion
  • Headache
  • Increased heart rate
  • Jaundice
  • Nausea and vomiting - Acute
  • Pallor
  • Tachypnea
  • Abdominal pain - Acute
  • Hepatomegaly - Acute
  • Retinal hemorrhage
  • Cool skin
  • Cough
  • Diaphoresis
  • Fever
  • Myalgia
  • Orthostatic hypotension - Acute
  • Shivering or rigors
  • Urticaria - Acute
  • Warm skin

Tests for Malaria
Suspected malaria and monitoring therapeutic response to known malaria
  • Peripheral blood smear examination, light microscopy: The presence of parasites in the stained peripheral blood is diagnostic of malaria.

Suspected Malaria
  • Complete blood count with white cell differential, manual: Atypical lymphocytes are universally present, and relative or absolute monocytosis occurs frequently.

Malaria
  • Hematocrit Determination: Decreased hematocrit is common with malaria and the cause is multifactorial. The most severe anemia occurs with falciparum infections.

Suspected Malaria
  • Plasma Random Glucose Measurement: Hypoglycemia with glucose < 40 mg/dL indicates poor prognosis in severe malaria. Falciparum malaria with hypoglycemia may mimic cerebral malaria.

Suspected cerebral malaria
  • Cerebrospinal fluid examination: Cerebrospinal fluid findings suggestive of cerebral malaria include elevated pressure, elevated protein levels, and lymphocytic pleocytosis.

Suspected malaria
Platelet count: Thrombocytopenia is a common finding in malaria, but it is rapidly reversible with appropriate antimalarial therapy.

Suspected and known malaria
Serum C reactive protein level: C-reactive protein levels correlates well with the severity of P falciparum malaria and the response to therapy.

Differential Diagnosis
  • Vivax malaria
  • Falciparum malaria
  • Quartan malaria
  • Ovale malaria
  • Congenital malaria
  • Relapsing fever
  • Visceral leishmaniasis
  • Typhoid fever
  • Influenza
  • Encephalitis
  • Meningitis
  • Pneumonia
  • Gastroenteritis - Acute
  • Appendicitis - Acute
  • Septicemia
  • Hepatitis
  • Thrombotic thrombocytopenic purpura - Acute
  • Subacute bacterial endocarditis

How is malaria treated?
Treatment for malaria should start as soon as possible. To treat malaria, doctor will prescribe drugs to kill the malaria parasite. Some parasites are resistant to malaria drugs. The type of medication and length of treatment depend on which parasite is causing your symptoms.

Antimalarial drugs include: 
  • Artemisinin drugs (artemether and artesunate)
  • Atovaquone
  • Chloroquine
  • Doxycycline
  • Mefloquine
  • Quinine

Treatment

Drug Therapy
Uncomplicated, chloroquine-resistant vivax malaria

QUININE
Adults: 
  • Quinine sulfate 542 mg base (=650 mg salt) orally three times daily for 3-7 days 
  • Primaquine phosphate 30 mg base orally once daily for 14 days 
  • Tetracycline 250 mg orally four times daily for 7 days

Pediatrics: 
  • Quinine sulfate 8.3 mg base/kg (=10 mg salt/kg) orally three times daily for 3-7 days 
  • Primaquine phosphate 0.5 mg base/kg orally once daily for 14 days 
  • Tetracycline 25 mg/kg/day orally divided four times daily for 7 days

QUININE
Adults:
  • Quinine sulfate 542 mg base (=650 mg salt) orally three times daily for 3-7 days 
  • Doxycycline 100 mg orally twice daily for 7 days 
  • Primaquine phosphate 30 mg base orally once daily for 14 days

Pediatrics (over age 8):
  • Quinine sulfate 8.3 mg base/kg (=10 mg salt/kg) orally three times daily for 3-7 days
  • Doxycycline 4 mg/kg/day orally in two divided doses daily for 7 days
  • Primaquine 0.5 mg base/kg orally daily for 14 days

Uncomplicated falciparum malaria or unidentified Plasmodium species

CHLOROQUINE PHOSPHATE
Adults:
  • 600 mg base (=1,000 mg salt) orally immediately, followed by 300 mg base (=500 mg salt) orally at 6, 24, and 48 hours (total dose 1,500 mg base [=2,500 mg salt])

Pediatrics:
  • 10 mg base/kg orally immediately, followed by 5 mg base/kg orally at 6, 24, and 48 hours (total dose 25 mg base/kg)

Uncomplicated malariae malaria

CHLOROQUINE PHOSPHATE
Adults:
  • 600 mg base (=1,000 mg salt) orally immediately, followed by 300 mg base (=500 mg salt) orally at 6, 24, and 48 hours (total dose 1,500 mg base [=2,500 mg salt])

Pediatrics:
  • 10 mg of base/kg orally immediately, followed by 5 mg base/kg orally at 6, 24, and 48 hours (total dose 25 mg base/kg)

Uncomplicated vivax or ovale malaria

CHLOROQUINE PHOSPHATE - PRIMAQUINE PHOSPHATE
Adults:
  • Chloroquine phosphate 600 mg base (=1,000 mg salt) orally immediately, followed by 300 mg base (=500 mg salt) orally at 6, 24, and 48 hours (total dose 1,500 mg base [=2,500 mg salt])
  • Primaquine phosphate 30 mg base orally once daily for 14 days

Pediatrics:
  • Chloroquine phosphate 10 mg of base/kg orally immediately, followed by 5 mg base/kg orally at 6, 24, and 48 hours (total dose 25 mg base/kg)
  • Primaquine phosphate 0.5 mg base/kg orally once daily for 14 days

Uncomplicated, chloroquine-sensitive malaria or falciparum malaria in pregnancy

CHLOROQUINE PHOSPHATE
Adults:
  • 600 mg base (=1,000 mg salt) orally immediately, followed by 300 mg base (=500 mg salt) orally at 6, 24, and 48 hours (total dose 1,500 mg base [=2,500 mg salt])

Uncomplicated, chloroquine-sensitive vivax or ovale malaria in pregnancy

CHLOROQUINE PHOSPHATE
Adults:
  • 600 mg base (=1,000 mg salt) orally immediately, followed by 300 mg base (=500 mg salt) orally at 6, 24, and 48 hours (total dose 1,500 mg base [=2,500 mg salt]); then 300 mg base (=500 mg salt) orally once weekly throughout pregnancy

Uncomplicated falciparum malaria or unidentified Plasmodium species resistant to chloroquine or of unknown resistance

QUININE
Adults:
  • Quinine sulfate 542 mg base (=650 mg salt) orally three times daily for 3-7 days Doxycycline 100 mg orally twice daily for 7 days

Pediatrics:
  • Quinine sulfate 8.3 mg base/kg (=10 mg salt/kg) orally three times daily for 3-7 days 
  • Doxycycline 4 mg/kg/day orally divided two times daily for 7 days

QUININE - TETRACYCLINE
Adults:
  • Quinine sulfate 542 mg base (=650 mg salt) orally three times daily for 3-7 days 
  • Tetracycline 250 mg orally four times daily for 7 days

Pediatrics (>8 years):
  • Quinine sulfate 8.3 mg base/kg (=10 mg salt/kg) orally three times daily for 3-7 days 
  • Tetracycline 25 mg/kg/day orally divided four times daily for 7 days

Uncomplicated chloroquine-resistant falciparum malaria in pregnancy

QUININE - CLINDAMYCIN HYDROCHLORIDE
Adults:
  • Quinine sulfate 542 mg base (=650 mg salt) orally three times daily for 3-7 days Clindamycin 20 mg base/kg/day orally divided into three doses for 7 days

Uncomplicated chloroquine-resistant vivax malaria in pregnancy

QUININE
Adults:
  • 650 mg salt orally three times daily for 7 days

Severe Falciparum Malaria

QUINIDINE GLUCONATE - DOXYCYCLINE
Adults:
  • Quinidine gluconate [6.25 mg base/kg (=10 mg salt/kg) loading dose IV over 1-2 hours, then 0.0125 mg base/kg/minute (=0.02 mg salt/kg/minute) continuous IV infusion for at least 24 hours OR 15 mg base/kg (=24 mg salt/kg) loading dose IV infused over 4 hours, followed by 7.5 mg base/kg (=12 mg salt/kg) IV infused over 4 hours every 8 hours, starting 8 hours after the loading dose]
  • Doxycycline 100 mg IV every 12 hours, switch to 100 mg orally twice daily when patient is able to take oral medication; total treatment course of 7 days

Pediatrics (< 45 kg):
  • Quinidine gluconate [6.25 mg base/kg (=10 mg salt/kg) loading dose IV over 1-2 hours, then 0.0125 mg base/kg/minute (=0.02 mg salt/kg/minute) continuous IV infusion for at least 24 hours OR 15 mg base/kg (=24 mg salt/kg) loading dose IV infused over 4 hours, followed by 7.5 mg base/kg (=12 mg salt/kg) infused over 4 hours every 8 hours, starting 8 hours after the loading dose]
  • Doxycycline 4 mg/kg IV every 12 hours, switch to 4 mg/kg/day orally divided two times daily when the patient is able to take oral medication; total treatment course of 7 days

Pediatrics (> 45 kg):
  • Quinidine gluconate [6.25 mg base/kg (=10 mg salt/kg) loading dose IV over 1-2 hours, then 0.0125 mg base/kg/minute (=0.02 mg salt/kg/minute) continuous IV infusion for at least 24 hours OR 15 mg base/kg (=24 mg salt/kg) loading dose IV infused over 4 hours, followed by 7.5 mg base/kg (=12 mg salt/kg) IV infused over 4 hours every 8 hours, starting 8 hours after the loading dose]
  • Doxycycline 100 mg IV every 12 hours, switch to 100 mg orally twice daily when patient is able to take oral medication; total treatment course of 7 days

QUINIDINE GLUCONATE - TETRACYCLINE
Adults:
  • Quinidine gluconate [6.25 mg base/kg (=10 mg salt/kg) loading dose IV over 1-2 hours, then 0.0125 mg base/kg/minute (=0.02 mg salt/kg/minute) continuous IV infusion for at least 24 hours OR 15 mg base/kg (=24 mg salt/kg) loading dose IV infused over 4 hours, followed by 7.5 mg base/kg (=12 mg salt/kg) IV infused over 4 hours every 8 hours, starting 8 hours after the loading dose]
  • Tetracycline 250 mg orally four times daily for 7 days

Pediatrics:
  • Quinidine gluconate [6.25 mg base/kg (=10 mg salt/kg) loading dose IV over 1-2 hours, then 0.0125 mg base/kg/minute (=0.02 mg salt/kg/minute) continuous IV infusion for at least 24 hours OR 15 mg base/kg (=24 mg salt/kg) loading dose IV infused over 4 hours, followed by 7.5 mg base/kg (=12 mg salt/kg) IV infused over 4 hours every 8 hours, starting 8 hours after the loading dose]
  • Tetracycline 25 mg/kg/day orally divided four times daily for 7 days

QUINIDINE GLUCONATE - Clindamycin
Adults:
  • Quinidine gluconate [6.25 mg base/kg (=10 mg salt/kg) loading dose IV over 1-2 hours, then 0.0125 mg base/kg/minute (=0.02 mg salt/kg/minute) continuous IV infusion for at least 24 hours OR 15 mg base/kg (=24 mg salt/kg) loading dose IV infused over 4 hours, followed by 7.5 mg base/kg (=12 mg salt/kg) IV infused over 4 hours every 8 hours, starting 8 hours after the loading dose]
  • Clindamycin 10 mg base/kg loading dose IV followed by 5 mg base/kg IV every 8 hours, switch to 20 mg base/kg/day orally divided three times daily when patient is able to take oral medication; total treatment course of 7 days

Pediatrics:
  • Quinidine gluconate [6.25 mg base/kg (=10 mg salt/kg) loading dose IV over 1-2 hours, then 0.0125 mg base/kg/minute (=0.02 mg salt/kg/minute) continuous IV infusion for at least 24 hours OR 15 mg base/kg (=24 mg salt/kg) loading dose IV infused over 4 hours, followed by 7.5 mg base/kg (=12 mg salt/kg) IV infused over 4 hours every 8 hours, starting 8 hours after the loading dose]
  • Clindamycin 10 mg base/kg loading dose IV followed by 5 mg base/kg IV every 8 hours, switch to 20 mg base/kg/day orally divided three times daily when a patient is able to take oral medication, total treatment course of 7 days

Prophylaxis of falciparum malaria

ATOVAQUONE/PROGUANIL HYDROCHLORIDE
Adults:
1 adult tablet orally daily

Pediatrics (11-20 kg):
1 pediatric tablet orally daily

Pediatrics (21-30 kg):
2 pediatric tablets orally daily

Pediatrics (31-40 kg):
3 pediatric tablets orally daily

Pediatrics (>40 kg):
1 adult tablet orally daily

CHLOROQUINE
Adults:
500 mg (300 mg base) orally once weekly, starting 1-2 weeks before travel, during travel, and 4 weeks post-travel

Pediatrics:
8.3 mg/kg (5 mg/kg base) orally once weekly (maximum dose 300 mg base)

Prophylaxis of chloroquine-resistant falciparum malaria

ATOVAQUONE/PROGUANIL HYDROCHLORIDE
Adults:
1 adult tablet (atovaquone 250 mg/proguanil 100 mg) orally daily with food 1-2 days prior to, during, and 7 days after travel

Pediatrics (11-20 kg):
Atovaquone 62.5 mg/proguanil 25 mg orally daily

Pediatrics (21-30 kg):
Atovaquone 125 mg/proguanil 50 mg orally daily

Pediatrics (31-40 kg):
Atovaquone 187.5 mg/proguanil 75 mg orally daily

Pediatrics (>40 kg):
Atovaquone 250 mg/proguanil 100 mg orally daily

Alternative prophylaxis of chloroquine-resistant falciparum malaria for nonpregnant adults

PRIMAQUINE PHOSPHATE
Adults:
30 mg base orally daily

Alternative prophylaxis of chloroquine-resistant falciparum malaria in pregnant adults

MEFLOQUINE HYDROCHLORIDE
Adults:
250 mg (228 mg base) orally once weekly, 1 week before, during, and 4 weeks after travel

What are the side effects of medications to treat malaria?
Antimalarial drugs can cause side effects. Be sure to tell a doctor about other medicines you’re taking, since antimalarial drugs can interfere with them. Depending on the medication, side effects may include:
Gastrointestinal (GI) issues such as nausea and diarrhea.
  • Headaches.
  • Increased sensitivity to sunlight.
  • Insomnia and disturbing dreams.
  • Psychological disorders and vision problems.
  • Ringing in the ears (tinnitus).
  • Seizures.

Can I prevent malaria?
If you live or travel in an area where malaria is common, talk to a doctor about taking medications to prevent malaria. You will need to take the drugs before, during, and after your stay.
You should also take precautions to avoid mosquito bites. To lower your chances of getting malaria, you should:
  • Apply mosquito repellent with DEET (diethyltoluamide) to exposed skin.
  • Drape mosquito netting over beds.
  • Put screens on windows and doors.
  • Treat clothing, mosquito nets, tents, sleeping bags and other fabrics with an insect repellent called permethrin.
  • Wear long pants and long sleeves to cover your skin.

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