para />
Children are particularly susceptible to severe disease.
All children, even infants, should receive chemoprophylaxis if traveling to an endemic area.
Malaria commonly resembles acute gastroenteritis in children.
Children with severe disease are particularly prone to hypoglycemia. Use IV fluids with glucose for maintenance and monitor blood glucose frequently.
‚
Pregnancy Considerations
Chloroquine is safe in the doses recommended for prevention and treatment of malaria; FDA pregnancy Category C.
Mefloquine is safe in the doses recommended for prevention and treatment of malaria; FDA pregnancy Category B.
Atovaquone-proguanil (Malarone) has not been studied in pregnant women; it has not been shown to cause birth defects or other problems in animal studies; FDA pregnancy Category C.
No primaquine (FDA class undetermined) or tetracyclines (FDA pregnancy Category D) in pregnancy
Quinine/Quinidine (FDA pregnancy Category C, respectively) should be used during pregnancy because benefit outweighs risk.
‚
COMPLEMENTARY & ALTERNATIVE MEDICINE
None. Deaths have resulted from using unapproved alternatives to recommended medications. ‚
SURGERY/OTHER PROCEDURES
Rarely, splenectomy must be performed in patients with splenic rupture. ‚
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Inpatient care for all cases of P. falciparum malaria. Hospitalize patients with signs of severe illness, regardless of species; outpatient care for others.
- Nonimmune patients with P. falciparum may progress from mild symptoms to death within 12 hours.
- All patients treated on outpatient basis should have follow-up within 24 hours.
IV Fluids
Maintenance IV fluids with glucose because of risk of hypoglycemia are recommended if unable to tolerate fluids by mouth. Excess fluids may result in iatrogenically induced pulmonary edema. ‚
Nursing
Observe for fluid excess, renal insufficiency (urine output), and hypoglycemia ‚
Discharge Criteria
Clinical improvement and ability to tolerate oral medications and fluids, with documented decreasing parasitemia levels ‚
ONGOING CARE
PATIENT EDUCATION
- Malarial chemoprophylaxis prior to travel
- Travel information may be obtained at the CDC travel Web site: http://www.cdc.gov/travel
- http://www.cdc.gov/malaria/new_info/2014/malaria_ebola.htm
PROGNOSIS
Malaria infection (particularly P. falciparum) can carry a high mortality if untreated. If diagnosed early and treated appropriately, the prognosis is excellent. ‚
COMPLICATIONS
- If not treated early: cerebral malaria, acute renal failure, acute gastroenteritis, respiratory distress syndrome, and massive hemolysis
- Other complications: seizures, anuria, delirium, coma, dysentery, algid malaria, blackwater fever, hyperpyrexia
- P. malariae: Nephrotic syndrome may develop in patients with chronic infection.
REFERENCES
11 World Health Organization. World Malaria Report 2014. Geneva, Switzerland: WHO Press; 2014.22 Cullen ‚ KA, Arguin ‚ PM. Malaria surveillance " ”United States, 2012. MMWR Surveil Summ. 2014;63(12):1 " “22.33 Centers for Disease Control and Prevention. Guidance for malaria diagnosis in patients suspected of ebola infection in the United States. http://www.cdc.gov/malaria/new_info/2014/malaria_ebola.htm. Updated January 15, 2015.44 Griffith ‚ KS, Lewis ‚ LS, Mali ‚ S, et al. Treatment of malaria in the United States: a systematic review. JAMA. 2007;297(20):2264 " “2277.
ADDITIONAL READING
- Centers for Disease Control and Prevention. Guidelines for treatment of malaria in the United States. http://www.cdc.gov/malaria/resources/pdf/treatmenttable.pdf. Updated July 1, 2013.
- Steinhardt ‚ LC, Magill ‚ AJ, Arguin ‚ PM. Review: malaria chemoprophylaxis for travelers to Latin America. Am J Trop Med Hyg. 2011;85(6):1015 " “1024.
CODES
ICD10
- B54 Unspecified malaria
- B50.9 Plasmodium falciparum malaria, unspecified
- B51.9 Plasmodium vivax malaria without complication
- B53.0 Plasmodium ovale malaria
- B52.9 Plasmodium malariae malaria without complication
- B52.0 Plasmodium malariae malaria with nephropathy
ICD9
- 084.6 Malaria, unspecified
- 084.0 Falciparum malaria [malignant tertian]
- 084.1 Vivax malaria [benign tertian]
- 084.3 Ovale malaria
- 084.2 Quartan malaria
SNOMED
- 61462000 Malaria (disorder)
- 62676009 Falciparum malaria (disorder)
- 27052006 Vivax malaria (disorder)
- 19341001 Ovale malaria (disorder)
- 27618009 Quartan malaria (disorder)
- 186796004 Plasmodium malariae malaria with nephropathy
- 4911000124103 Plasmodium falciparum malaria with complication (disorder)
CLINICAL PEARLS
- Consider malaria in travelers returning from endemic areas who present with fever or nonspecific flulike illness.
- Early identification and aggressive treatment, particularly of nonimmune persons with suspected or confirmed P. falciparum malaria, is important.
- Patients who develop clinical malaria despite chemoprophylaxis should be treated with medication that is different from their chemoprophylaxis drug.
- P. falciparum malaria can be rapidly fatal and should be cared for in the inpatient setting.