Malaria

Quartan malaria; Falciparum malaria; Biduoterian fever; Blackwater fever; Tertian malaria; Plasmodium Last reviewed: June 9, 2011. Malaria is a parasitic disease that involves high fevers, shaking chills, flu-like symptoms, and anemia.

Causes, incidence, and risk factors

Malaria is caused by a parasite that is passed from one human to another by the bite of infected Anopheles mosquitoes. After infection, the parasites (called sporozoites) travel through the bloodstream to the liver, where they mature and release another form, the merozoites. The parasites enter the bloodstream and infect red blood cells. The parasites multiply inside the red blood cells, which then break open within 48 to 72 hours, infecting more red blood cells. The first symptoms usually occur 10 days to 4 weeks after infection, though they can appear as early as 8 days or as long as a year after infection. The symptoms occur in cycles of 48 to 72 hours. Most symptoms are caused by:

The release of merozoites into the bloodstream Anemia resulting from the destruction of the red blood cells Large amounts of free hemoglobin being released into circulation after red blood cells break open

Malaria can also be transmitted from a mother to her unborn baby (congenitally) and by blood transfusions. Malaria can be carried by mosquitoes in temperate climates, but the parasite disappears over the winter. The disease is a major health problem in much of the tropics and subtropics. The CDC estimates that there are 300-500 million cases of malaria each year, and more than 1 million people die from it. It presents a major disease hazard for travelers to warm climates. In some areas of the world, mosquitoes that carry malaria have developed resistance to insecticides. In addition, the parasites have developed resistance to some antibiotics. These conditions have led to difficulty in controlling both the rate of infection and spread of this disease. There are four types of common malaria parasites. Recently, a fifth type, Plasmodium knowlesi, has been causing malaria in Malaysia and areas of southeast Asia. Another type, falciparum malaria, affects more red blood cells than the other types and is much more serious. It can be fatal within a few hours of the first symptoms.

Symptoms

Anemia Bloody stools Chills Coma Convulsion Fever Headache Jaundice Muscle pain Nausea Sweating Vomiting

Signs and tests

During a physical examination, the doctor may find an enlarged liver or enlarged spleen. Malaria blood smears taken at 6 to 12 hour intervals confirm the diagnosis. A complete blood count (CBC) will identify anemia if it is present.

Treatment
Malaria, especially Falciparum malaria, is a medical emergency that requires a hospital stay. Chloroquine is often used as an anti-malarial medication. However, chloroquine-resistant infections are common in some parts of the world. Possible treatments for chloroquine-resistant infections include:

The combination of quinidine or quinine plus doxycycline, tetracycline, or clindamycin Atovaquone plus proguanil (Malarone) Mefloquine or artesunate The combination of pyrimethamine and sulfadoxine (Fansidar)

The choice of medication depends in part on where you were when you were infected. Medical care, including fluids through a vein (IV) and other medications and breathing (respiratory) support may be needed.

Expectations (prognosis)
The outcome is expected to be good in most cases of malaria with treatment, but poor in Falciparum infection with complications.

Complications

Brain infection (cerebritis) Destruction of blood cells (hemolytic anemia)

Kidney failure Liver failure Meningitis Respiratory failure from fluid in the lungs (pulmonary edema) Rupture of the spleen leading to massive internal bleeding (hemorrhage)

Calling your health care provider

Call your health care provider if you develop fever and headache after visiting the tropics.

Prevention
Most people who live in areas where malaria is common have gotten some immunity to the disease. Visitors will not have immunity, and should take preventive medications. It is important to see your health care provider well before your trip, because treatment may need to begin as long as 2 weeks before travel to the area, and continue for a month after you leave the area. In 2006, the CDC reported that most travelers from the U.S. who contracted malaria failed to take the right precautions. The types of anti-malarial medications prescribed will depend on the area you visit. According to the CDC, travelers to South America, Africa, the Indian subcontinent, Asia, and the South Pacific should take one of the following drugs: mefloquine, doxycycline, chloroquine, hydroxychloroquine, or Malarone. Even pregnant women should take preventive medications because the risk to the fetus from the medication is less than the risk of catching this infection. People who are taking anti-malarial medications may still become infected. Avoid mosquito bites by wearing protective clothing over the arms and legs, using screens on windows, and using insect repellent. Chloroquine has been the drug of choice for protecting against malaria. But because of resistance, it is now only suggested for use in areas where Plasmodium vivax, P. oval, and P. malariae are present. Falciparum malaria is becoming increasingly resistant to anti-malarial medications. For travelers going to areas where Falciparum malaria is known to occur, there are several options for malaria prevention, including mefloquine, atovaquone/proguanil (Malarone), and doxycycline. Travelers can call the CDC for information on types of malaria in a certain area, preventive drugs, and times of the year to avoid travel. See: www.cdc.gov

References
1. Fairhurst RM, Wellems TE. Plasmodium species (Malaria). In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2009:chap 275.

2. Krogstad DJ. Malaria. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier. 2007:chap 366.

What is malaria?

Malaria is an infectious disease caused by a parasite, Plasmodium, which infects red blood cells. Malaria is characterized by cycles of chills, fever, pain, and sweating. Historical records suggest malaria has infected humans since the beginning of mankind. The name "mal aria" (meaning "bad air" in Italian) was first used in English in 1740 by H. Walpole when describing the disease. The term was shortened to "malaria" in the 20th century. C. Laveran in 1880 was the first to identify the parasites in human blood. In 1889, R. Ross discovered that mosquitoes transmitted malaria. Of the four common species that cause malaria, the most serious type is Plasmodium falciparum malaria. It can be life-threatening. However, another relatively new species, Plasmodium knowlesi, is also a dangerous species that is typically found only in long-tailed and pigtail macaque monkeys. Like P. falciparum, P. knowlesi may be deadly to anyone infected. The other three common species of malaria (P. vivax, P. malariae, and P. ovale) are generally less serious and are usually not life-threatening. It is possible to be infected with more than one species of Plasmodium at the same time. Currently, about 2 million deaths per year worldwide are due to Plasmodium infections. The majority occur in children under 5 years of age in sub-Saharan African countries. There are about 400 million new cases per year worldwide. Most people diagnosed in the U.S. obtained their infection outside of the country, usually while living or traveling through an area where malaria is endemic.
What are malaria symptoms and signs?

The symptoms characteristic of malaria include flulike illness with fever, chills, muscle aches, and headache. Some patients develop nausea, vomiting, cough, and diarrhea. Cycles of chills, fever, and sweating that repeat every one, two, or three days are typical. There can sometimes be vomiting, diarrhea, coughing, and yellowing (jaundice) of the skin and whites of the eyes due to destruction of red blood cells and liver cells. People with severe P. falciparum malaria can develop bleeding problems, shock, liver or kidney failure, central nervous system problems, coma, and can die from the infection or its complications. Cerebral malaria (coma, or altered mental status or seizures) can occur with severe P. falciparum infection. It is lethal if not treated quickly; even with treatment, about 15%-20% die.
How is malaria transmitted?

The life cycle of the malaria parasite (Plasmodium) is complicated and involves two hosts, humans and Anopheles mosquitoes. The disease is transmitted to humans when an infected Anopheles mosquito bites a person and injects the malaria parasites (sporozoites) into the

blood. This is shown in Figure 1, where the illustration shows a mosquito taking a blood meal (circle label 1 in Figure 1).

Figure 1: CDC illustration of the life cycles of malaria parasites, Plasmodium spp. SOURCE: CDC

Sporozoites travel through the bloodstream to the liver, mature, and eventually infect the human red blood cells. While in red blood cells, the parasites again develop until a mosquito takes a blood meal from an infected human and ingests human red blood cells containing the parasites. Then the parasites reach the Anopheles mosquito's stomach and eventually invade the mosquito salivary glands. When an Anopheles mosquito bites a human, these sporozoites complete and repeat the complex Plasmodium life cycle. P. ovale and P. vivax can further complicate the cycle by producing dormant stages (hypnozoites) that may not develop for weeks to years.