Rosen & Barkin's 5-Minute Emergency Medicine Consult (432 page)

Pregnant patients, especially primigravida, at higher risk

DIAGNOSIS

• Timing:
  
  • P. falciparum—exhibits within 8 wk of return
    
  • P. vivax—delayed several months
    
  • Most symptomatic within 1 yr
    
• General:
  
  • Malaise
    
  • Chills
    
  • Fever—usually >38°C
    
  • Classic malaria paroxysm:
    
    • 15 min to 1 hr of chills
      
    • Followed by 2–6 hr of nondiaphoretic fever ≤39–42°C
      
    • Profuse diaphoresis followed by defervescence
      
    • Pattern every 48 hr (P. vivax and P. ovale) or every 72 hr (P. falciparum)
      
    • Fever pattern may be varied; rare to have classical fever.
      
  • Orthostatic hypotension
    
  • Myalgias/arthralgias
    
  • Hematology
    
  • Hemolysis:
    
    • Blackwater fever; named from the dark color of the urine partially due to hemolysis in overwhelming P. falciparum infections
      
  • Jaundice
    
  • Splenomegaly:
    
    • More common in chronic infections
      
    • May cause splenic rupture
      
• CNS—cerebral malaria:
  
  • Headache
    
  • Focal neurologic findings
    
  • Mental status changes
    
  • Coma
    
  • Seizures
    
• GI:
  
  • Emesis
    
  • Diarrhea
    
  • Abdominal pain
    
• Pulmonary:
  
  • Shortness of breath
    
  • Rales
    
  • Pulmonary edema
    
• Severe malaria:
  
  • One or more of the following:
    
    • >20% mortality even with optimal management
      
    • Prostration; unable to sit up by oneself
      
    • Impaired consciousness
      
    • Respiratory distress or pulmonary edema
      
    • Seizure
      
    • Circulatory collapse
      
    • Abnormal bleeding
      
    • Jaundice
      
    • Hemoglobinuria
      
    • Severe anemia
      

Oil emersion light microscopy of a thick-smear Giemsa stain:

• Demonstrates intraerythrocytic malaria parasites
  
• Cannot exclude diagnosis without three negative smears in 48 hr
  
• Only high degrees of parasitemia will be evident on a standard CBC smear.
  

• CBC:
  
  • Anemia—25%
    
  • Thrombocytopenia—70% have <150
    
  • Leukocytopenia
    
• Electrolytes, BUN, creatinine, glucose:
  
  • Renal failure
    
  • Hypoglycemia (rare)
    
  • Lactic acidosis
    
  • Hyponatremia
    
• Urinalysis
  
• Liver function tests:
  
  • Increased in 25%
    
  • Increased bilirubin and lactate dehydrogenase are the signs of hemolysis
    

Chest radiograph—for pulmonary edema

• Immunofluorescence assay, enzyme-linked immunosorbent assay, or DNA probes:
  
  • Differentiates the type of Plasmodium present
    
  • 5–7% will have mixed infections.
    
• Lumbar puncture/ CSF analysis:
  
  • Performed to distinguish cerebral malaria from meningitis
    
  • CSF lactate/protein elevated with malaria
    
  • CSF pleocytosis/hypoglycemia absent with malaria
    

• Meningitis
  
• Encephalitis
  
• Stroke
  
• Acute renal failure
  
• Acute hemolytic anemia
  
• Sepsis
  
• Hepatitis
  
• Viral diarrheal illness
  
• Hypoglycemic coma
  
• Heat stroke
  

TREATMENT

• ABCs
  
• 0.9% NS fluid bolus for hypotension
  
• Immediate cooling if temperature >40°C
  
• Acetaminophen
  
• Mist/cool-air fans
  
• Naloxone, D
  ₅₀
  W (or Accu-Chek), and thiamine if altered mental status
  

• Dependent on considering this diagnosis and identifying the type of malaria present and geographic area of acquisition
  
• Assume drug resistant until proven otherwise.
  
• To counter resistance Artemisinin combinations of antimalarials are recommended 1st line.
  
• Artemisinin-based combination therapy – choice is based on geographic region, check WHO database
  
  • Artemether + Lumefantrine
    
  • Artesunate + Amodiaquine
    
  • Artesunate + Mefloquine
    
  • Artesunate + Sulfadoxine–Pyrimethamine
    
• Severe falciparum—IV treatment:
  
  • Artesunate can be given IV or IM
    
  • Artemisinin can be given rectally
    
• Supportive therapy for complications
  
• Chemoprophylaxis: Must be based on region of travel, check WHO database
  
  • Malarone
    
    • Daily medication
      
    • Very well tolerated
      
    • Safe in children >5 kg – pediatric dosing
      
    • Unsafe in pregnancy
      
    • 250/100 mg PO daily
      
    • Begin 1–2 days prior to entering malaria area and continue for 7 days after leaving area
      
  • Chloroquine:
    
    • Drug of choice for travelers who want weekly medication
      
    • Safe in pregnancy
      
    • 300 mg PO weekly
      
    • Begin 2 wk prior to departure and continue for 4 wk after return
      
  • Mefloquine:
    
    • Weekly medication
      
    • Safe in pregnancy; do not use with certain psychiatric conditions
      
    • 250 mg PO weekly
      
    • Begin 2 wk before departure and continue for 4 wk after return
      
  • Doxycycline:
    
    • Daily medication
      
    • Least expensive
      
    • Unsafe in pregnancy
      
    • Unsafe in children <8 y/o
      
    • Risk with sun exposure
      
    • 100 mg PO daily
      
    • Begin 1 day prior to entering area and continue for 4 wk after return
      
  • Primaquine:
    
    • Daily medication
      
    • Cannot use in G6PD deficiency
      
    • Unsafe in pregnancy
      
    • 30 mg PO every day
      
    • Begin 1 day prior to entering area and continue 1 wk after return
      
• Vaccine is not available, but several are in field trials.
  

• Acetaminophen: 500 mg (peds: 10–15 mg/kg) PO q4–6h; do not exceed 5 doses/24 h; max. 4 g/24 h
  
• Artemether (20 mg)–lumefantrine (120 mg): 6 dose regimen PO BID × 3 days
  
• Artesunate (50 mg) + Amodiaquine (153 mg): 3 dose regimen PO QD × 3 days
  
• Artesunate (50 mg) + Sulfadoxine
  
• Pyrimethamine (500/25): 3 dose regimen 1 tabs of Artesunate PO QD × 3 and 1 tab
  
• Sulfadoxine–Pyrimethamine PO QD × 1 day
  
• Artesunate (50 mg) + Mefloquine (250 mg): 3 dose regimen 1 tab of Artesunate PO QD × 3 days and Mefloquine PO split over 2–3 days.
  
• Dextrose: D
  ₅₀
  W 1 amp—50 mL or 25 g (peds: D
  ₂₅
  W 2–4 mL/kg) IV
  
• Naloxone (Narcan): 2 mg (peds: 0.1 mg/kg) IV or IM initial dose
  
• Thiamine (vitamin B
  ₁
  ): 100 mg (peds: 50 mg) IV or IM
  

FOLLOW-UP

• ICU admission for severe P. falciparum infection
  
• Suspected acute P. falciparum infection
  
• Severe dehydration
  
• Inability to tolerate oral solution/medication
  
• >3% of RBC containing parasites
  

• Non–P. falciparum infection
  
• Able to tolerate oral medications
  

Consider in patients with appropriate exposure/epidemiology and in exposed patients with fever and consistent signs and symptoms.

• American Academy of Pediatrics, Committee on Infectious Diseases.
  Red Book
  . 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012.
  
• Centers for Disease Control and Prevention. Malaria. Available at
  www.cdc.gov/malaria/
  .
  
• Centers for Disease Control and Prevention. Malaria hotline: 770-488-7788.
  
• Centers for Disease Control and Prevention. Traveler’s Health. Available at
  www.cdc.gov/travel/contentYellow Book.aspx
  .
  
• www.cdc.gov/malaria/resources/pdf/treatment.ttable.pdf
  
• Garner P, Gelband H, Graves P, et al. Systemic reviews in malaria: Global policies need global reviews.
  Infect Dis Clin North Am.
  2009;23:387–404.
  
• WHO. Guidelines for the Treatment of Malaria. 2006; 266 p.
  

CODES