General Medical Officer (GMO) Manual: Clinical Section

Malaria
Department of the Navy
Bureau of Medicine and Surgery
Peer Review Status: Internally Peer Reviewed

(1) Etiology protozoan parasites

The etiology of malaria is from the protozoan parasites of the genus Plasmodium with an asexual stage in humans
and a sexual stage in mosquitoes. The four genus are P. falciparum, P. vivax, P.ovale, and P. malariae.

(2) Transmission and Distribution

The Anopheles mosquito is essential for the development, multiplication, and spread of malarial disease. The
bite from an infected female Anopheles mosquito can occur at night, but is particularly noted during dusk and
dawn periods and is seen at altitudes less than 2200 meters. Malaria is found throughout the tropical and
subtropical areas of the world usually between 45 N and 40 S latitude with 200-300 million infections and 1.5
million deaths estimated per year. Most deaths are attributable to P. falciparum.

(3) Clinical presentation symptoms

Signs may range from asymptomatic (usually semi-immune patient) to a rapidly fatal disease. The nonimmune
patient usually has acute onset of fever (102-106°) and rigors (100 percent), headache (66-89 percent), nausea and
emesis (41-64 percent), and myalgias (40-57 percent). Physical findings include fever, diaphoresis, tachypnea,
conjunctival icterus, occasional pulmonary rales, palpable spleen (49-88 percent) and liver (31-44 percent), and
alterations of mentation.

(4) Laboratory Evaluation

Abnormal laboratory findings reflect the severity of hemolysis.

• CBC: anemia (25-50 percent), leukopenia (25-36 percent), thrombocytopenia (30-80 percent).

• Peripheral Blood Smear: look for malarial parasites (see diagnosis below).

• Urine: + protein, urobilinogen, conjugated bilirubin, and hemoglobin.

• Chemistry Panel (Lytes, Glucose, BUN, CRE): Hypoglycemia is frequently seen in children
and pregnant females. Hyponatremia may occur.

• Liver Function Tests: The transaminases AST/ALT are often elevated.

(5) Diagnosis
Diagnosis requires a high index of suspicion and demonstration of malarial parasites in the peripheral blood.
Smears should be obtained initially every 6-8 hours while the diagnosis is in question for at least 3 days. Smears
should be followed every 8-12 hours, if seriously ill, to monitor the effects of therapy and then daily until
parasitemia is resolved. Trophozoites should ideally decrease by 75 percent in first 48 hours and disappear within
7 days although gametes may persist. Thin smears are an alternative if the lab is unable to prepare and interpret
thick smears.

(6) Differential diagnosis

This can include malaria, typhoid fever or other salmonelloses, dengue, influenza, meningococcemia or other
sepsis, amebiasis, relapsing fever, viral encephalitis, rickettsial diseases, leptospirosis, and endocarditis.
 (7) Complicated Malaria
A patient with malaria and any one or more of the following should be regarded as complicated: *
(a) Hyperparasitemia: >3 percent RBC's parasitized.

(b) Hypoglycemia: Serum glucose <60 mg/dl.

(c) Severe anemia: Hct <21 percent or a rapidly falling Hct.

(d) Renal failure: Urine output <400 ml/day, BUN >40 mg/dl or CRE >4 mg/dl.

(e) Hyponatremia: Serum Na < 125 mg/dl.

(f) Cerebral malaria: Any history or finding of delirium or decreased level of consciousness.

(g) Prolonged hyperpyrexia >24 hours.

(h) High output diarrhea or protracted emesis.

(i) Any significant cardiac or pulmonary dysfunction.

(j) Pregnancy: Increased risk to mother and child.

*Cases of complicated malaria should be presumed to be secondary to P. falciparum and should be treated as a
medical emergency with parenteral therapy initially.

(8) Malarial Resistance

P. falciparum resistance to chloroquine is wide-spread throughout Asia, Africa, and South America. Only
sensitive organisms are reliably found in Central America above Panama, Haiti, the Dominican Republic, and the
Middle East. Resistance to sulfadoxine/pyrimethamine (Fansidar) is present in Southeast Asia, Africa, and in the
Amazon basin of Brazil. Mefloquine resistance has been widely reported from Southeast Asia and many parts of
Africa. P. Vivax chloroquine resistance has been recently described from Papua, New Guinea, and Irian Jaya. P.
vivax primaquine resistance has been reported from Southeast Asia and South America.

(9) Malaria Prevention

(a) Essential concepts

(1) Assessment of risk and selection of appropriate chemoprophylaxis.

(2) Use of personal protective measures.

(3) Command enforcement of chemoprophylaxis and personal protective measures.

(4) Early identification and investigation of possible cases.

(5) Mosquito vector control measures, if appropriate.

(b) Personal protective measures

(1) Avoid night-time exposures when possible.

(2) Wear long sleeve shirts and long pants with sleeves rolled down.

(3) Use insect repellent (long acting DEET preparations) and treat uniforms with permethrin.

(4) Use mosquito bed netting.

(5) Spray mosquito bed netting with permethrin spray.

 (c) Chemoprophylaxis

P. falciparum presence
Drug Toxicity
in Region

Chloroquine-sensitive Chloroquine 300 mg/wk GI upset

CNS: vertigo
Mefloquine 250 mg/wk or
Chloroquine-resistant Cardiac: A-V bloc
Doxycycline 100mg/d
Photosensitivity, GI upset

(10) Chloroquine and Mefloquine

These medications should be taken at least 2 weeks before entering an endemic area. Doxycycline can be started
1-2 days before exposure. All agents should be continued for 4 weeks after leaving the risk area. Primaquine is
generally indicated for terminal prophylaxis for military exposures. The following points emphasize the
importance of chemoprophylaxis:
(a) No prophylaxis regimen is 100 percent effective.

(b) A single bite may result in infection.

(c) Any exposure to an endemic area may place an individual at risk.

(11) Malaria Treatment
(a) Suspicion of malaria.

(b) Patient exposed to endemic area.

(c) Fever, rigor, sweats, HA, NNID, altered mental status.

(d) Peripheral smear - (+) malarial parasites.

(12) Essentials of Malaria Treatment
(a) Recognize infection ASAP.

(b) Institute effective therapy immediately.

(c) Anticipate complications.

(d) Treat complications and prevent death.

(e) Prevent recrudescence and relapse.

(f) Recognize and treat recrudescence and relapse.

(g) Reduce transmission.

(13) High suspicion of malaria

If the possibility of malarial infection is high in a severely ill patient, and one is not able to demonstrate parasites,
strongly consider empiric therapy for P. falciparum malaria while continuing to work through the differential
diagnosis.

(14) Steroids are contraindicated in cases of cerebral malaria.

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References

(a) Navy Medical Guide to Malaria Prevention and Control, NEHC- TM 6250.98-2, (8/98), Navy
Environmental Health Center, Norfolk, VA 23513-2617
Reviewed and revised by CAPT Beecham, MC, USN, Naval Environmental Preventive Medicine Unit 6,
Pearl Harbor, HI (1999).