RISK FACTORS: Usually traveling and/or living in endemic area (75% of P. falciparum cases from Sub-Sahara Africa), Rarely, blood transfusion or mother-to-fetus transmission
APPROPRIATE HEALTH CARE Malaria ( P. falciparum ) in a non-immune patient (a person not living in an endemic area) is a medical emergency. These patients should be hospitalized. Do not send home if malaria is suspected and tests are pending. Outpatient for others, except during acute phase if blood products or close observation is required.
GENERAL MEASURES In severe cases anemia, renal failure, multisystem failure, hypotension and cardiovascular collapse may occur. Coma and seizures are not uncommon. Hypoglycemia in children,
particularly after quinine is started, is common.
SURGICAL MEASURES Rarely splenectomy for ruptured spleen.
ACTIVITY May resume activity as soon as the fever is under control. Avoid strenuous exercise if splenomegaly.
DIET No restrictions; as tolerated
PATIENT EDUCATION Prevention of future exposures. These measures include prevention of mosquito bites and malarial chemoprophylaxis.
DRUG(S) OF CHOICE
. Atovaquone-proguanil (Malarone) 250 mg/100 mg : adults, 2 tablets bid for 3 days. Children, 11-20 kg 1/2
adult tablet bid, 21-30 kg 1 adult tablet bid, 31-40 kg 1 1/2 adult tablets bid
. Oral therapy for chloroquine-resistant P. falciparum
. Quinine sulfate plus doxycycline or plus pyrimethamine-sulfadoxine (Fansidar) or plus tetracycline
- Adults, quinine sulfate 650 mg salt tid for 3-7 days plus doxycycline 100 mg bid for 7 days or plus Fansidar 3 tablets on last day of quinine or plus tetracycline 250 mg qid for 7 days
- Children, quinine sulfate 10 mg salt/kg (max 650 mg salt) tid for 3-7 days plus doxycycline (not for <8 years of age) 2 mg/kg bid for 7 days or plus Fansidar 1/2 tablet/10 kg on last day of quinine or plus tetracycline (not for < 8 years of age) 6.25 mg/kg qid for 7 days
. Oral therapy for P. ovale , P. malariae , chloroquinesensitive P. falciparum and chloroquine-sensitive P. vivax
. Chloroquine phosphate:
- Adults, 600 mg base (1 gm salt) followed by 300 mg at 6, 24 and 48 hours
- Children, 10 mg base/kg (max of 600 mg) then 5 mg/kg at 6, 24 and 48 hours
. Primaquine phosphate (added to chloroquine therapy for cure of dormant forms of P. vivax and P. ovale )
- Adults, 30 mg base (52.6 mg) daily for 2 weeks or 45 mg base (79 mg) weekly for 8 weeks
- Children, 0.6 mg base/kg daily for 2 weeks
. Oral therapy for chloroquine-resistant P. vivax
. Quinine sulfate plus doxycycline or plus tetracycline: see above for dosages
. Mefloquine: adults 1250 mg once (usually divided as 750 mg, then 500 mg 8 hours later). Children 15 mg/kg, then 10 mg/kg 8 hours later.
. For severe infection requiring parenteral therapy
. Quinidine gluconate: adults and children, 10 mg/kg in normal saline over 1-2 hours followed by 0.02
mg/kg/min continuous infusion or repeat initial dose every 8 hours until oral therapy can be started
ALTERNATIVE DRUGS Oral therapy regardless of plasmodium species: mefloquine: adults, 1250
mg once (may divide as 750 mg and 500 mg over 12 hours); children, 15 mg/kg followed by 10 mg/kg at 12
hours
PATIENT MONITORING Watch for relapse of clinical symptoms
PREVENTION/AVOIDANCE
. Use malarial chemoprophylaxis when in an endemic area. In 2002, all deaths (8) in U.S. were of patients
who did not take chemoprophylaxis appropriately.
. Oral chemoprophylaxis for areas with chloroquine-resistant Plasmodium species
. Mefloquine (begin 2 weeks before arrival and continue for 4 weeks after leaving area):
- Adults: 250 mg (1 tablet) weekly
- Children: <15 kg 5 mg/kg; 15-19 kg 1/4 tablet weekly; 20-30 kg 1/2 tablet weekly; 31-45 kg 3/4 tablet weekly; >45 kg 1 tablet weekly
. Malarone (begin 1-2 days before arrival and continue for 1 week after leaving area):
- Adults: 250 mg / 100 mg (1 adult tablet) daily
- Children: 11-20 kg 62.5 mg / 25 mg (1 pediatric tablet) daily; 21-30 kg (2 pediatric tablets daily); 31-40 kg (3 pediatric tablets daily); >40 kg 1 adult tablet daily
. Doxycycline (begin 1-2 days before arrival and continue for 4 weeks after leaving area): - Adults: 100 mg daily
- Children: 2 mg/kg daily, up to 100 mg daily (not for children < 8 years)
. Oral chemoprophylaxis for areas with chloroquine-sensitive Plasmodium species
. Chloroquine phosphate (begin 1-2 weeks before arrival and continue for 4 weeks after leaving area):
- Adults: 300 mg base (500 mg salt) weekly
- Children: 5 mg base/kg weekly up to 300 mg base weekly
. Personal measures (variable efficacy)
. DEET-containing insect repellent
. Clothing that covers most of the body
. Mosquito nets and clothing impregnated with permethrin
. Air-conditioning
POSSIBLE COMPLICATIONS
. P. falciparum : if not treated early, may cause cerebral malaria, acute renal failure, acute gastroenteritis,
pulmonary edema, massive hemolysis, and splenic rupture. Death from malaria is virtually limited to P.
falciparum infection.
. P. malariae : nephrotic syndrome may develop in patients with chronic infection
. Other complications: seizures, anuria, delirium, coma, dysentery, algid malaria, blackwater fever, hyperpyrexia
EXPECTED COURSE/PROGNOSIS
Only P. falciparum infection carries a poor prognosis with high mortality if untreated. However, if diagnosed
early and treated appropriately the prognosis is excellent.