SEVERE MALARIA:

Severe Malaria is defined as severe manifestation of malaria that may contribute to major organ dysfunction or failure (e.g. coma, renal failure or pulmonary edema) or even death if treatment is not proper or urgent. Severe malaria is mainly caused by Plasmodium falciparum but not all cases of P. falciparum are severe. The treatment of this condition requires hospitalization and specialist care.

                                  

In case of P. falciparum infection the symptoms usually begin 10 to 35 days after mosquito injects the parasite. Initial “prodromal” symptoms are followed by the paroxysms. Unlike other forms of malaria the paroxysms are not regular and patients often do have fever between the paroxysms. The parasite load is high in falciparum infection because this type can infect red blood cells of any age. This is one of the reasons for severity of malaria caused by P. falciparum. The most important and potentially fatal complication is cerebral malaria that occurs commonly in infants, pregnant women and non-immune travelers to high-risk areas. Untreated P. falciparum malaria is fatal in about 20% of people and prompt and adequate treatment is required to prevent fatalities.

The case of severe malaria mainly presents with history of fever (in the last 03 days) with one or more of the following manifestations:

v  Cerebral manifestations

·         Altered consciousness and/ or behavior.

·         Convulsions (more than two generalized seizures in 24 hours)

·         Coma (Unrousable coma, not attributable to any other cause)

v  Circulatory manifestations:

·         Dehydration

·         Circulatory overload (Bilateral basal crept, raised JVP, dependent edema)

·         Circulatory collapse (systolic BP < 80 mm Hg in adults, with cold clammy skin)

v  Acute renal manifestations:

·         24 hours urine output < 400 ml in adults or 2 ml/kg body weight in children or anurea.

·         No improvement with dehyderation

·         Serum creatanine > 03 mg/dl or 265 mmol/L

·         Hemoglubinuria

v  Respiratory manifestations:

·         Pulmonary edema or difficult breathing

·         Acute respiratory distress syndrome.

v  Blood related manifestations:

·         Severe anemia (hemoglobin < 05gm/dl or hematocrit less 15%)

·         Significant bleeding / disseminated intra-vascular coagulation

v  Metabolic manifestations:

·         Hypoglycemia (blood glucose less than 2.2 mmol/L or < 40 mg/dl)

·         Metabolic acidosis (Arterial ph < 7.25 or plasma bicarbonate < 15 mmol/L, venous blood lactate > 6 mmol/L)

v  Other manifestations:

·         Jaundice

·         Hyperparasitemia (parasite count > 10,000 parasites / micro litter of blood)

These severe malaria manifestations can occur singly or, more commonly, in combination in the same patient. Severe malaria can mimic many other diseases. The most important of these are all types of meningitis, typhoid fever and septicemia. Other differential diagnosis include influenza, dengue and other arbovirus infections, hepatitis, the relapsing fevers, hemorrhagic fever, all types of viral encephalitis (including rabies) and gastroenteritis.

In pregnant women malaria must be distinguished from sepsis arising in the uterus, urinary tract or breast. In children convulsions due to severe malaria must be differentiated from febrile convulsions. In febrile convulsions patients regain consciousness in 30-60 minutes.