Malaria: Falciparum

Malaria: Falciparum

Falciparum malaria is the commonest

commonest

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, and most severe, type of malaria.

Clinical features

Falciparum malaria typically presents with symptoms suggestive of a flu-like illness. The classical triad of symptoms includes paroxysms of fever, chills, and sweating. These symptoms may occur every 48 hours corresponding to the erythrocytic cycle of the Plasmodium falciparum parasite. Fever is often high, intermittent, and may be accompanied by rigors. Initial manifestations can be non-specific and include malaise, headache, and myalgia, which might be mistaken for a viral syndrome.

General features of falciparum malaria

Returning traveller with fever/flu-like symptoms, anaemia/jaundice/renal impairment --> ?falciparum malaria

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Importance: 90

• fever: The hallmark of malaria, typically cyclical, often accompanied by sweating and sometimes rigors.
• gastrointestinal:
  • anorexia, nausea, vomiting, and abdominal pain are frequent
  • diarrhoea can occasionally be a feature, more commonly in children
  • patients may exhibit mild jaundice and occasional pruritus
• respiratory: Cough and, in some cases, mild tachypnoea may occur, though primary respiratory complications are rare in non-severe cases.
• musculoskeletal: Generalised body aches and joint pains are common.
• neurological:
  • headache is prominent and often severe.
  • dizziness and sleep disturbances may also be observed.
• cardiovascular: Tachycardia may be evident, and although hypotension is more typical of severe malaria, it can occasionally be seen in non-severe cases as well.
• haematological:
  • thrombocytopaenia is the most significant haematological finding and can occur in the absence of severe disease.
  • mild anaemia may also be present.
• renal: While acute kidney injury is associated with severe malaria, non-severe cases might show mild to moderate increases in creatinine or blood urea nitrogen levels.

Feature of severe falciparum malaria

• schizonts on a blood film
  Schizonts and late stages of trophozoites are typically sequested in Plasmodium falciparum infection and their presence on the peripheral smear indicates severe disease
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  Importance: 99
• parasitaemia > 2%
• hypoglycaemia
• acidosis
• temperature > 39 °C
• severe anaemia
• complications as below

Complications

• cerebral malaria: seizures, coma
• acute renal failure: blackwater fever, secondary to intravascular haemolysis, mechanism unknown
• acute respiratory distress syndrome (ARDS)
• hypoglycaemia
• disseminated intravascular coagulation (DIC)

Management

Uncomplicated falciparum malaria

• strains resistant to chloroquine are prevalent in certain areas of Asia and Africa
• the 2010 WHO guidelines recommend artemisinin-based combination therapies (ACTs) as first-line therapy
• examples include artemether plus lumefantrine, artesunate plus amodiaquine, artesunate plus mefloquine, artesunate plus sulfadoxine-pyrimethamine, dihydroartemisinin plus piperaquine

Severe falciparum malaria

• a parasite counts of more than 2%
  Parasitaemia > 2% is a feature of severe malaria
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  Importance: 96
  will usually need parenteral treatment irrespective of clinical state
• intravenous artesunate
  Severe falciparum malaria - intravenous artesunate
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  Importance: 82
  is now recommended by WHO in preference to intravenous quinine
  Quinine is no longer recommended as a first-line treatment for complicated/severe falciparum malaria
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  Importance: 53
• if parasite count > 10% then exchange transfusion
  Exchange transfusion should be considered in cases of severe parasitaemia (>10%)
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  Importance: 98
  should be considered
• shock may indicate coexistent bacterial septicaemia - malaria rarely causes haemodynamic collapse

+PassMedicine Notes

Falciparum malaria is the commonest, and most severe, type of malaria.

Clinical features

Falciparum malaria typically presents with symptoms suggestive of a flu-like illness. The classical triad of symptoms includes paroxysms of fever, chills, and sweating. These symptoms may occur every 48 hours corresponding to the erythrocytic cycle of the Plasmodium falciparum parasite. Fever is often high, intermittent, and may be accompanied by rigors. Initial manifestations can be non-specific and include malaise, headache, and myalgia, which might be mistaken for a viral syndrome.

General features of falciparum malaria

• fever: The hallmark of malaria, typically cyclical, often accompanied by sweating and sometimes rigors.
• gastrointestinal:
• anorexia, nausea, vomiting, and abdominal pain are frequent
• diarrhoea can occasionally be a feature, more commonly in children
• patients may exhibit mild jaundice and occasional pruritus
• respiratory: Cough and, in some cases, mild tachypnoea may occur, though primary respiratory complications are rare in non-severe cases.
• musculoskeletal: Generalised body aches and joint pains are common.
• neurological:
• headache is prominent and often severe.
• dizziness and sleep disturbances may also be observed.
• cardiovascular: Tachycardia may be evident, and although hypotension is more typical of severe malaria, it can occasionally be seen in non-severe cases as well.
• haematological:
• thrombocytopaenia is the most significant haematological finding and can occur in the absence of severe disease.
• mild anaemia may also be present.
• renal: While acute kidney injury is associated with severe malaria, non-severe cases might show mild to moderate increases in creatinine or blood urea nitrogen levels.

Feature of severe falciparum malaria

• schizonts on a blood film
• parasitaemia > 2%
• hypoglycaemia
• acidosis
• temperature > 39 °C
• severe anaemia
• complications as below

Complications

• cerebral malaria: seizures, coma
• acute renal failure: blackwater fever, secondary to intravascular haemolysis, mechanism unknown
• acute respiratory distress syndrome (ARDS)
• hypoglycaemia
• disseminated intravascular coagulation (DIC)

Management

Uncomplicated falciparum malaria

• strains resistant to chloroquine are prevalent in certain areas of Asia and Africa
• the 2010 WHO guidelines recommend artemisinin-based combination therapies (ACTs) as first-line therapy
• examples include artemether plus lumefantrine, artesunate plus amodiaquine, artesunate plus mefloquine, artesunate plus sulfadoxine-pyrimethamine, dihydroartemisinin plus piperaquine

Severe falciparum malaria

• a parasite counts of more than 2% will usually need parenteral treatment irrespective of clinical state
• intravenous artesunate is now recommended by WHO in preference to intravenous quinine
• if parasite count > 10% then exchange transfusion should be considered
• shock may indicate coexistent bacterial septicaemia - malaria rarely causes haemodynamic collapse