A 17-year-old male came to the emergency room with a history of fever, chills, abdominal pain and headache for one day. The fever was to 102.5° and came and went. His headache was generalized and occurred mainly with the fever. His abdominal pain was more in the right upper quadrant with no radiation. He had nausea and therefore was not eating and was drinking less. The past medical and social history revealed he had recently come to the United State from eastern Africa. He said that he had had malaria several times in the past and the symptoms he was having were similar. The review of systems showed no dysuria with normal bowel and bladder function. He denied genital lesions or discharge, cough, rhinorrhea, or rashes.
The pertinent physical exam showed a male in moderate distress who appeared mildly dehydrated. His abdominal examination showed a mildly tender liver that was 3-4 cm below his ribs. The rest of his examination was normal. The pertinent laboratory evaluation demonstrated increased liver enzymes with an AST of 307 U/L. His BUN was 45 mg/dl and his creatinine was 1.3 mg/dl. The hemoglobin was 14.3 mg/dl, platelets of 216 x 1000/mm2 and 1% schistocytes. His blood smear was positive for parasites (3%) that were eventually identified as Plasmodium falciparum. The radiologic evaluation of an abdominal ultrasound showed no appendicitis, normal kidneys and mildly increased liver size.
The diagnosis of acute malaria was made. He was admitted to the floor but transferred to the ICU because of liver and renal function tests trending upward with hemoglobin and platelets trending downward over the next 18 hours. He was started on Coartem™ and quinine after consultation with the Centers for Disease Control. As one physician noted, “We don’t want to make mistakes with a disease that other doctors in the world with fewer resources treat and manage very well. We just don’t do this very often in the United States.” His condition stabilized and he was transferred to the floor on day 3. On day 4 he was almost afebrile, his liver enzymes had almost normalized, his hemoglobin was stable and his platelets were trending upward. Unfortunately, he had some emesis of his medication. Because there was a limited supply, he was changed to Malarone™ after consultation with the Centers for Disease Control. On day 5, he felt very tired but good, and he was discharged on day 6 to followup with the infectious disease specialist within the week with local lab testing in 2 days.
Malaria is a life-threatening yet preventable and curable disease caused by parasites. In humans, there are 4 species that cause malaria: Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae,and Plasmodium ovale. Plasmodium falciparum is the most deadly and Plasmodium falciparum and Plasmodium vivax are the most common. Plasmodium parasites are transmitted by bites from Anopheles mosquitoes from an infected human. The incubation period is 7-30 days. In 2012, it is estimated to have caused 627,000 deaths mostly among African children. Mortality rates have been decreasing but children, pregnant women, people with HIV/AIDs and immigrants and international travelers from non-endemic areas are most at risk. At risk is ~50% of the world’s population with ongoing transmission in 97 countries especially in sub-Saharan Africa, but also Asia, Latin America, the Middle East and Europe.
Prevention is key. Insecticidal spraying and especially consistent use of long-lasting insecticidal mosquito nets are important strategies. There are problems with use of the nets including general wear. The World Health Organization is beginning research to evaluate real-world use of mosquito nets and potential strategies to increase their use and longevity. A vaccine is also being evaluated in clinical trials.
Malaria is usually categorized into uncomplicated or severe disease. People with uncomplicated malaria usually will have fever, chills, sweats, headaches, body aches, nausea and emesis and fatigue/malaise. People with complicated malaria may have severe anemia, coagulopathies, acute respiratory distress syndrome, mental status changes kidney failure and/or hemoglobinuria, liver failure, signs of impending cardiovascular collapse such as hypotension, metabolic acidosis and hypoglycemia. Patients may present with any of these symptoms and/or signs of these problems such as acute mental status changes and jaundice or hepatomegaly with liver involvement.
Laboratory confirmed cases of malaria in the United States are reportable to local or state public health agencies. The Centers for Disease Control will provide help with diagnosis and treatment of suspected or confirmed cases by calling the CDC Malaria Hotline toll free at 770-488-7788, 855-856-4713 or 770-448-7100 (after hours).
Malaria treatment depends on the area of the world the patient contracted the malaria in because of differences in the typical species of parasite and also potential antibiotic resistance to anti-malaria drugs. For uncomplicated malaria, the World Health Organization recommends use of oral artemisinin-based combination therapies for Plasmodium falciparum. It is always used in combination to help preserve its efficacy. One example is Coartem™ which is Artemether-lumefantrine. Other options recommended by the Centers for Disease Control in the United States include Malarone™ (atovaquone-proquanil) alone, or quinine plus either doxycycline, tetracycline or clincamycin. Mefloquine is also an option but one of the other 3 options is preferred. For severe malaria, the World Health Organization recommends patients be treated with injectable intramuscular or intravenous artesunate as the first line treatment. Artesunate followed by Malarone, doxycycline, clindamycin or mefloquine has an investigation new drug status in the United States and clinicians should contact the CDC for possible use. Another option recommended by the CDC is quinidine gluconate given IV, along with doxycycline, tetracycline, or clindamycin given IV or orally depending on the drug and if the patient is able to take oral medication.
Questions for Further Discussion
1. What species of malaria are common in your location?
2. How effective have been malaria prevention techniques in your location?
3. For patients traveling internationally to malaria endemia areas, how to you counsel them regarding malaria prevention?
- Specialty: Infectious Diseases | Preventive Medicine and Health Maintenance | Travel Medicine | Pharmacology / Toxicology
- Age: Teenager
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Centers for Disease Control. Disease. Available from the Internet at: http://www.cdc.gov/malaria/about/disease.html#severe. (rev.2/8/10, cited 2/10/14)
Centers for Disease Control. Guidelines for Treatment of Malaria in the United States. Available from the Internet at: http://www.cdc.gov/malaria/resources/pdf/treatmenttable.pdf (7/1/13, cited 2/10/14)
Centers for Disease Control. Treatment of Malaria: Guidelines For Clinicians (United States)Part 2: General Approach to Treatment and Treatment of Uncomplicated Malaria Available from the Internet at: http://www.cdc.gov/malaria/diagnosis_treatment/clinicians2.html (7/13, cited 2/10/14)
World Health Organization. Overview of malaria treatment. Available from the Internet at: http://www.who.int/malaria/areas/treatment/overview/en/index.html (rev. 3/6/13, cited 2/10/14)
World Health Organization. Antimalarial drug efficacy. Available from the Internet at: http://www.who.int/malaria/areas/treatment/drug_efficacy/en/index.html (rev. 11/8/13, cited 2/10/14)
World Health Organization. Factsheet on the World Malaria Report 2013. Available from the Internet at: http://www.who.int/malaria/media/world_malaria_report_2013/en/index.html (rev. 12/13, cited 2/10/14)
WHO Malaria Policy Advisory Committee and Secretariat. Malaria Policy Advisory Committee to the WHO: conclusions and recommendations of September 2013 meeting. Malar J. 2013 Dec 20;12(1):456.
World Health Organization. Malaria. Available from the Internet at: http://www.who.int/mediacentre/factsheets/fs094/en/index.html (rev. 12/2013, cited 2/10/14).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital