History

Fact Explanation
Introduction Plasmodium falciparum malaria is a protazoal infection transmitted by female anopeles mosquito. This can be commonly seen in tropical and subtropical countries. Following the mosquito bite plasmodium protazoa enters to the human circulation in the stage of Sporozoites and with in few minutes they enters the liver. Nearly for next 2 week they multiply with in hepatocytes and released to the circulation as the stage, merozoites. these thousands of merozoites enters to the red blood cells and start further multiplication producing schizonts. These schizonts are ruptured and released in to the circulation promoting furter multiplication by entering to new red blood cells (erythrocytic stage). Female anopeles mosquito can infect at this stage and can spread to the other humans. [1][2][5]
Fever and chills Fever occurs with the rupture and release of red blood cell contents which are pyrogens. So the fever pattern will usually depend on the length of the erythrocytic stage. But in plasmodium falciparum malaria there will be aperiodic fever pattern called malignant fever.[6][7][8][52].
Non specific constitutional symptoms like headache, malaise, myalgia, anorexia These are associated with the fever and occur with the release of inflammatory contents to the circulation with the rupture of erythrocytes[9][10][11].
Easy fatiguability, lethargy and shortness of breath With the excessive premature destruction of erythrocytes, patient will develop anaemia[12]13][14].
Yellowish discoloration of eyes With the excessive red cell destruction there will be increased bilirubin production causing jaundice. With the hepatocyte destruction at initial stage also will have some contribution for this[15][16][17].
Abdominal pain/ discomfort Patient will develop hepato-splenomegaly with the excessive red cell destruction[18][19][20]. Rarely splenic rupture can occure with the acute massive splenomegally. So there will be features of peritonitis such as sudden onset sever abdominal pain, ill health and faintishness secondary to circulatory collapse[21][22][23].
Evidence of cerebral malaria There will be confusion, drowsiness, coma, seizures, body weakness and sensory loss. Cerebral malaria is one of life threatening complication associated with plasmodium falciparum malaria. This is due to the sequestration effect of infected red blood cells which stick to each other anf to the endothelium of the blood vessels (cytoadherence) blocking cerebral circulation[24][25][26].
Evidence of metabolic acidosis This is also another life threatening complicaltion patient will present with sudden onset difficulty in brathing. This is due to the lactic acid production with the infection causing lactic acidosis[24][26][27][28].
Features of hypoglycaemia Patient will present will symptoms like faintishness, sweating and development of seizures. With the excessive usage for cell turnover leads to hypoglycaemia. This is usually associated with the severe disease and common among children, during pregnancy and in patients currently on anti malarial drugs like quinine[29][30][31].
Symptoms of acute renal failure Generalized body swelling and reduced or absent urine output are the symptoms which patient can present with. This is secondary to acute tubular necrosis which occur as a complication of sequestration causing hypoperfusion[32][33][34]. Some time acute renal failure occurs with another severe complication called blackwater fever. This is due to the haemoglobin urea associated with excessive red cell destruction. The condition is associated with symptoms like red coloured urine, rapidly developed anaemia features as mentioned above and high fever and chills. So this haemoglobinuria can finally leads to acute renal failure[35][36].
Evidence of pulmonary oedema Shortness of breath, chest pain, cough, wheezing and pink frothy sputum are the main symptoms associated with pulmonary oedema. This also resulting from the pulmonary vessel occlusion with sequestration. This can finally leads to Acute Respiratory Distress Syndrome[37][38][39][40].
Evidence of increased bleeding tendency Bleeding from puncture sites, cannula can be seen. With the excessive erythropoiesis, other blood cell production from bone marrow will be depleted. So there will be low platelet counts. With the excessive workload on liver, there will be poor clotting factor production. So both of these conditions finally resulting increased bleeding tendency[41][42][43].
Evidence of shock This is another complication which can be seen in severe malaria (algid malaria). The primary causes are super added bacterial infection causing septicaemia, dehydration causing hypovolaemia and splenic rupture causing peritonitis. Symptoms will be ill health, dizziness, unresponsiveness, coma[49][50][51].
Obstetric history As pregnant mothers and fetuses of infected mothers are at risk of getting severe complication even death and in pregnacy treatment options are different, Obstetric history is very important. Plasmodium falciparum malaria will be associated with miscarriages, pre term deliveries, still births and IUGR.[3][4][14][44]
Evidence of vascular occlusion on other organs With the effect of sequestration and adherent of red blood cells to vascular endothelium thrombi formation can take place in any organ with symptoms of hypoperfusion. eg: Myocardial infarction/ anginan (chest pain, shortess of brath, faintishness), acute limb ischemia (acute limb pain especially during moving, skin discoloration), mesenteric ischmia (abdominal pain), retinal ischemia (visual disturbances)[45][46][47][48].
References
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  7. DURAND R, PRENDKI V, CAILHOL J, HUBERT V, RALAIMAZAVA P, MASSIAS L, BOUCHAUD O, LE BRAS J. Plasmodium falciparum Malaria and Atovaquone-Proguanil Treatment Failure Emerg Infect Dis [online] 2008 Feb, 14(2):320-322 [viewed 17 November 2014] Available from: doi:10.3201/eid1402.070945
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  10. JOLLY DT. Malaria: An Important Emergency Room Diagnosis Can Fam Physician [online] 1985 Nov:2173-2178 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2327749
  11. VADIVELAN M, DUTTA T. Recent advances in the management of Plasmodium knowlesi infection Trop Parasitol [online] 2014, 4(1):31-34 [viewed 17 November 2014] Available from: doi:10.4103/2229-5070.129158
  12. GOSLING RD, HSIANG MS. Malaria and Severe Anemia: Thinking beyond Plasmodium falciparum PLoS Med [online] 2013 Dec, 10(12):e1001576 [viewed 17 November 2014] Available from: doi:10.1371/journal.pmed.1001576
  13. CASALS-PASCUAL C, HUANG H, LAKHAL-LITTLETON S, THEZENAS ML, KAI O, NEWTON CR, ROBERTS DJ. Hepcidin demonstrates a biphasic association with anemia in acute Plasmodium falciparum malaria Haematologica [online] 2012 Nov, 97(11):1695-1698 [viewed 17 November 2014] Available from: doi:10.3324/haematol.2012.065854
  14. DROUIN J, ROCK G, JOLLY EE. Plasmodium falciparum malaria mimicking autoimmune hemolytic anemia during pregnancy. Can Med Assoc J [online] 1985 Feb 1, 132(3):265-267 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1346708
  15. SAYA RP, DEBABRATA G, SAYA GK. Malarial Hepatopathy and Its Outcome in India N Am J Med Sci [online] 2012 Oct, 4(10):449-452 [viewed 17 November 2014] Available from: doi:10.4103/1947-2714.101981
  16. ZUBAIRI AB, NIZAMI S, RAZA A, MEHRAJ V, RASHEED AF, GHANCHI NK, KHALED ZN, BEG MA. Severe Plasmodium vivax Malaria in Pakistan Emerg Infect Dis [online] 2013 Nov, 19(11):1851-1854 [viewed 17 November 2014] Available from: doi:10.3201/eid1911.130495
  17. ALEXANDRE MA, FERREIRA CO, SIQUEIRA AM, MAGALHãES BL, MOURãO MP, LACERDA MV, ALECRIM MD. Severe Plasmodium vivax Malaria, Brazilian Amazon Emerg Infect Dis [online] 2010 Oct, 16(10):1611-1614 [viewed 17 November 2014] Available from: doi:10.3201/eid1610.100685
  18. WILSON S, JONES FM, MWATHA JK, KIMANI G, BOOTH M, KARIUKI HC, VENNERVALD BJ, OUMA JH, MUCHIRI E, DUNNE DW. Hepatosplenomegaly associated with chronic malaria exposure: evidence for a pro-inflammatory mechanism exacerbated by schistosomiasis Parasite Immunol [online] 2009 Feb, 31(2):64-71 [viewed 17 November 2014] Available from: doi:10.1111/j.1365-3024.2008.01078.x
  19. WILSON S, VENNERVALD BJ, DUNNE DW. Chronic Hepatosplenomegaly in African School Children: A Common but Neglected Morbidity Associated with Schistosomiasis and Malaria PLoS Negl Trop Dis [online] , 5(8):e1149 [viewed 17 November 2014] Available from: doi:10.1371/journal.pntd.0001149
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  24. IDRO R, MARSH K, JOHN CC, NEWTON CR. Cerebral Malaria; Mechanisms Of Brain Injury And Strategies For Improved Neuro-Cognitive Outcome Pediatr Res [online] 2010 Oct, 68(4):267-274 [viewed 17 November 2014] Available from: doi:10.1203/PDR.0b013e3181eee738
  25. KURTZHALS JA, REIMERT CM, TETTE E, DUNYO SK, KORAM KA, AKANMORI BD, NKRUMAH FK, HVIID L. Increased eosinophil activity in acute Plasmodium falciparum infection--association with cerebral malaria Clin Exp Immunol [online] 1998 May, 112(2):303-307 [viewed 17 November 2014] Available from: doi:10.1046/j.1365-2249.1998.00586.x
  26. JOHN CC, KUTAMBA E, MUGARURA K, OPOKA RO. Adjunctive therapy for cerebral malaria and other severe forms of Plasmodium falciparum malaria Expert Rev Anti Infect Ther [online] 2010 Sep, 8(9):997-1008 [viewed 17 November 2014] Available from: doi:10.1586/eri.10.90
  27. ZOUGBéDé S, MILLER F, RAVASSARD P, REBOLLO A, CICéRON L, COURAUD PO, MAZIER D, MORENO A. Metabolic acidosis induced by Plasmodium falciparum intraerythrocytic stages alters blood-brain barrier integrity J Cereb Blood Flow Metab [online] 2011 Feb, 31(2):514-526 [viewed 17 November 2014] Available from: doi:10.1038/jcbfm.2010.121
  28. ACKERMAN H. Management of severe malaria: Enthusiasm for fluid resuscitation dampened by lung water Crit Care Med [online] 2013 Apr, 41(4):1139-1140 [viewed 17 November 2014] Available from: doi:10.1097/CCM.0b013e318283cab1
  29. ODEH M. Falciparum malaria and hypoglycaemia. Postgrad Med J [online] 1993 Apr, 69(810):325 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2399664
  30. ATABANI GS, SAEED BO, ELSEED BA, BAYOUMI MA, HADI NH, ABU-ZEID YA, BAYOUMI RA. Hypoglycaemia in Sudanese children with cerebral malaria. Postgrad Med J [online] 1990 Apr, 66(774):326-327 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2429396
  31. SHALEV O, TSUR A, RAHAV G. Falciparum malaria-induced hypoglycaemia in a diabetic patient. Postgrad Med J [online] 1992 Apr, 68(798):281-282 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2399263
  32. SOWUNMI A. Renal function in acute falciparum malaria. Arch Dis Child [online] 1996 Apr, 74(4):293-298 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1511488
  33. MEREMO AJ, KILONZO SB, MUNISI D, KAPINGA J, JUMA M, MWANAKULYA S, MPONDO B. Acute renal failure in a Caucasian traveler with severe malaria: a case report Clin Case Rep [online] 2014 Jun, 2(3):82-85 [viewed 17 November 2014] Available from: doi:10.1002/ccr3.65
  34. RAFIEIAN-KOPAEI M, NASRI H, ALIZADEH F, ATAEI B, BARADARAN A. Immunoglobulin A Nephropathy and Malaria falciparum Infection; a Rare Association Iran J Public Health [online] , 42(5):529-533 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684463
  35. LON C, SPRING M, SOK S, CHANN S, BUN R, ITTIVERAKUL M, BUATHONG N, THAY K, KONG N, YOU Y, KUNTAWUNGINN W, LANTERI CA, SAUNDERS DL. Blackwater fever in an uncomplicated Plasmodium falciparum patient treated with dihydroartemisinin-piperaquine Malar J [online] :96 [viewed 17 November 2014] Available from: doi:10.1186/1475-2875-13-96
  36. GOBBI F, AUDAGNOTTO S, TRENTINI L, NKURUNZIZA I, CORACHAN M, DI PERRI G. Blackwater Fever in Children, Burundi Emerg Infect Dis [online] 2005 Jul, 11(7):1118-1120 [viewed 17 November 2014] Available from: doi:10.3201/eid1107.041237
  37. JOHNSON S, WILKINSON R, DAVIDSON RN. Tropical respiratory medicine. 4. Acute tropical infections and the lung. Thorax [online] 1994 Jul, 49(7):714-718 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC475066
  38. MARTELL RW, KALLENBACH J, ZWI S. Pulmonary oedema in the falciparum malaria. Br Med J [online] 1979 Jun 30, 1(6180):1763-1764 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1599415
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  40. GOYAL JP, MAKWANA AM. Comparison of Clinical Profile between P. vivax and P. falciparum Malaria in Children: A Tertiary Care Centre Perspective from India Malar Res Treat [online] 2014:132672 [viewed 17 November 2014] Available from: doi:10.1155/2014/132672
  41. MOXON CA, HEYDERMAN RS, WASSMER SC. Dysregulation of coagulation in cerebral malaria Mol Biochem Parasitol [online] 2009 Aug, 166(2-3):99-108 [viewed 17 November 2014] Available from: doi:10.1016/j.molbiopara.2009.03.006
  42. SARAVU K, DOCHERLA M, VASUDEV A, SHASTRY BA. Thrombocytopenia in vivax and falciparum malaria: an observational study of 131 patients in Karnataka, India Ann Trop Med Parasitol [online] 2011 Dec, 105(8):593-598 [viewed 17 November 2014] Available from: doi:10.1179/2047773211Y.0000000013
  43. GUPTA NK, BANSAL SB, JAIN UC, SAHARE K. Study of thrombocytopenia in patients of malaria Trop Parasitol [online] 2013, 3(1):58-61 [viewed 17 November 2014] Available from: doi:10.4103/2229-5070.113914
  44. ROWE JA, KYES SA. The role of Plasmodium falciparum var genes in malaria in pregnancy Mol Microbiol [online] 2004 Aug, 53(4):1011-1019 [viewed 17 November 2014] Available from: doi:10.1111/j.1365-2958.2004.04256.x
  45. SULAIMAN H, ISMAIL MD, JALALONMUHALI M, ATIYA N, PONNAMPALAVANAR S. Severe Plasmodium falciparum infection mimicking acute myocardial infarction Malar J [online] , 13(1):341 [viewed 17 November 2014] Available from: doi:10.1186/1475-2875-13-341
  46. JAIN K, CHAKRAPANI M. Acute Myocardial Infarction in a Hospital Cohort of Malaria J Glob Infect Dis [online] 2010, 2(1):72-73 [viewed 17 November 2014] Available from: doi:10.4103/0974-777X.59258
  47. MASSE E, HANTSON P. Plasmodium falciparum Malaria Complicated by Symmetrical Peripheral Gangrene, Bowel Ischemia, Repeated Candidemia, and Bacteraemia Case Rep Med [online] 2014:696725 [viewed 17 November 2014] Available from: doi:10.1155/2014/696725
  48. GUPTA A, DWIVEDI Y, SAXENA AK, JOSHI K. Symmetrical peripheral gangrene with Plasmodium falciparum malaria J Nat Sci Biol Med [online] 2013, 4(1):262-264 [viewed 17 November 2014] Available from: doi:10.4103/0976-9668.107323
  49. DE ALENCAR AC FILHO, DE LACERDA MV, OKOSHI K, OKOSHI MP. Malaria and Vascular Endothelium Arq Bras Cardiol [online] 2014 Aug, 103(2):165-169 [viewed 22 November 2014] Available from: doi:10.5935/abc.20140088
  50. LACERDA MV, MOURãO MP, ALEXANDRE MA, SIQUEIRA AM, MAGALHãES BM, MARTINEZ-ESPINOSA FE, SANTANA FILHO FS, BRASIL P, VENTURA AM, TADA MS, COUTO VS, SILVA AR, SILVA RS, ALECRIM MG. Understanding the clinical spectrum of complicated Plasmodium vivax malaria: a systematic review on the contributions of the Brazilian literature Malar J [online] :12 [viewed 22 November 2014] Available from: doi:10.1186/1475-2875-11-12
  51. FROM: THE INDIAN SOCIETY OF CRITICAL CARE MEDICINE TROPICAL FEVER GROUP, SINGHI S, CHAUDHARY D, VARGHESE GM, BHALLA A, KARTHI N, KALANTRI S, PETER JV, MISHRA R, BHAGCHANDANI R, MUNJAL M, CHUGH TD, RUNGTA N. Tropical fevers: Management guidelines Indian J Crit Care Med [online] 2014 Feb, 18(2):62-69 [viewed 22 November 2014] Available from: doi:10.4103/0972-5229.126074
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Examination

Fact Explanation
General examination look for general well being of the patient, hydration, any features of nutritional deficiency (angular stomatitis, chelitis), rashes and lymphadenopathy (in malaria there will be no rashes or lymphadenopathy)[1][2][3].
Temperature Temperature need to be recorded and a temperature card should be be maintained to see the fever pattern. this is important in differentiating various types of malaria ( p. vivax and p.ovale- tertian fever pattern, p.malariae- quartan fever pattern, p. falciparum- aperiodic fever pattern). [4][5][6][49].
Pallor Patient will be pale due to excessive destruction of red blood cells[7][8][9].
Jaundice With the excessive red cell destruction causing increase in bilirubin production and hepatocyte destruction at initial stage leads to the jaundice[10][11][12].
Abdominal examination This will reveals the massive hepato-splenomegly (especially with chronic disease) due to the excess workload on both organs[13][14][15]. Examination should be done carefully as the massive spenomegally is at risk of rupture. In a case of ruptured spleen, patient will be ill, may be in a shock, generalized abdominal tenderness, guarding and rigidity will be present (due to the peritoneal irritation with blood).[16][17][18]
Central nervous system examination With the cerebral malaria t5here will be confusion, drowsiness, coma, development of seizures and focal neurological signs like motor and sensory impairment and cranial nerve palsy. In a case of cerebellar involvement there will be signs of imbalance and incordination[19][20][21].
Signs of metabolic acidosis Patient will be rapidly and deeply breathing (Kussmaul's breathing), vomiting due to lactic acidosis[19][21][22][23].
Signs of hypoglycaemia There will be signs of autonomic nervous system involvement, like excessive sweating and tremor. patient will be anxious. Due to the neurological involvement there will be signs like confusion, drowsiness, coma and development of seizures. Rarely transient focal neurological signs (eg: body weakness) can occur[24][25][26].
Signs of acute renal failure There will be generalized oedema associated with oliguria or anuria[27][28][29]. in blackwater fever there will bedark red coloured urine( haemoglobinuria) on examination[30][31].
Signs of pulmonary oedema On examination patient will be dyspnoic and there will be coughing and wheezing. Sputum will be pink and frothy. Lung examination will reveals rhonchi and bibasal end-inspiratory crackles. In the presence of Acute Respiratory Distress Syndrome there will be cyanosis, tacycardia, tachypnoea and bilateral end-inspiratory crackles.[32][33][34][35]
Signs of increased bleeding tendency There will be excessive bleeding from puncture sites and and cannula sites. Spontaneous bleeding can occur causing gum bleeding, nasal bleeding, , Per Vaginal bleeding, haematuria and Per Rectal bleeding[36][37][38].
Signs of shock In shock patient will be pale, tachycardic, capillary refilling time < 2 seconds, dyspnois and oliguric with evidence of primary cause[46][47][48].
Signs of pregnancy complications In a miscarriage there will be per vaginal bleeding and abdominal pain, In a pre term delivery watery/ blood stained vaginal discharge will be present with pre term labour pains. Still birth there will be absent foetal movements and foetal heart sounds[9][39][40][41].
Signs of other vascular occlusion Signs will depend on the organ affecting with the vascular occlusion. eg: Myocardial infarction/ angina there will be chest pain, shortess of brath and faintishness), In acute limb ischemia patient will be in a severe pain with limited movements, limb will be cold and there will be skin discoloration mesenteric ischmia there will be adominal tenderness Fundoscopic examination in retinal ischemia will show pale disk, exudate and retinal hemorrhages like signs[42][43][44][45].
References
  1. BARTOLONI A, ZAMMARCHI L. Clinical Aspects of Uncomplicated and Severe Malaria Mediterr J Hematol Infect Dis [online] , 4(1):e2012026 [viewed 17 November 2014] Available from: doi:10.4084/MJHID.2012.026
  2. JOLLY DT. Malaria: An Important Emergency Room Diagnosis Can Fam Physician [online] 1985 Nov:2173-2178 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2327749
  3. VADIVELAN M, DUTTA T. Recent advances in the management of Plasmodium knowlesi infection Trop Parasitol [online] 2014, 4(1):31-34 [viewed 17 November 2014] Available from: doi:10.4103/2229-5070.129158
  4. GODSE KV, ZAWAR V. Malaria Presenting as Urticaria Indian J Dermatol [online] 2012, 57(3):237-238 [viewed 17 November 2014] Available from: doi:10.4103/0019-5154.96213
  5. DURAND R, PRENDKI V, CAILHOL J, HUBERT V, RALAIMAZAVA P, MASSIAS L, BOUCHAUD O, LE BRAS J. Plasmodium falciparum Malaria and Atovaquone-Proguanil Treatment Failure Emerg Infect Dis [online] 2008 Feb, 14(2):320-322 [viewed 17 November 2014] Available from: doi:10.3201/eid1402.070945
  6. MCCARRA MB, AYODO G, SUMBA PO, KAZURA JW, MOORMANN AM, NARUM DL, JOHN CC. Antibodies to Plasmodium Falciparum Erythrocyte Binding Antigen-175 are Associated with Protection from Clinical Malaria Pediatr Infect Dis J [online] 2011 Dec, 30(12):1037-1042 [viewed 17 November 2014] Available from: doi:10.1097/INF.0b013e31822d1451
  7. GOSLING RD, HSIANG MS. Malaria and Severe Anemia: Thinking beyond Plasmodium falciparum PLoS Med [online] 2013 Dec, 10(12):e1001576 [viewed 17 November 2014] Available from: doi:10.1371/journal.pmed.1001576
  8. CASALS-PASCUAL C, HUANG H, LAKHAL-LITTLETON S, THEZENAS ML, KAI O, NEWTON CR, ROBERTS DJ. Hepcidin demonstrates a biphasic association with anemia in acute Plasmodium falciparum malaria Haematologica [online] 2012 Nov, 97(11):1695-1698 [viewed 17 November 2014] Available from: doi:10.3324/haematol.2012.065854
  9. DROUIN J, ROCK G, JOLLY EE. Plasmodium falciparum malaria mimicking autoimmune hemolytic anemia during pregnancy. Can Med Assoc J [online] 1985 Feb 1, 132(3):265-267 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1346708
  10. SAYA RP, DEBABRATA G, SAYA GK. Malarial Hepatopathy and Its Outcome in India N Am J Med Sci [online] 2012 Oct, 4(10):449-452 [viewed 17 November 2014] Available from: doi:10.4103/1947-2714.101981
  11. ) ZUBAIRI AB, NIZAMI S, RAZA A, MEHRAJ V, RASHEED AF, GHANCHI NK, KHALED ZN, BEG MA. Severe Plasmodium vivax Malaria in Pakistan Emerg Infect Dis [online] 2013 Nov, 19(11):1851-1854 [viewed 17 November 2014] Available from: doi:10.3201/eid1911.130495
  12. ALEXANDRE MA, FERREIRA CO, SIQUEIRA AM, MAGALHãES BL, MOURãO MP, LACERDA MV, ALECRIM MD. Severe Plasmodium vivax Malaria, Brazilian Amazon Emerg Infect Dis [online] 2010 Oct, 16(10):1611-1614 [viewed 17 November 2014] Available from: doi:10.3201/eid1610.100685
  13. WILSON S, JONES FM, MWATHA JK, KIMANI G, BOOTH M, KARIUKI HC, VENNERVALD BJ, OUMA JH, MUCHIRI E, DUNNE DW. Hepatosplenomegaly associated with chronic malaria exposure: evidence for a pro-inflammatory mechanism exacerbated by schistosomiasis Parasite Immunol [online] 2009 Feb, 31(2):64-71 [viewed 17 November 2014] Available from: doi:10.1111/j.1365-3024.2008.01078.x
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  15. INGRASSIA F, GADALETA A, MAGGI P, PASTORE G. Plasmodium falciparum malaria and Parvovirus B19; a case of acute co-infection BMC Infect Dis [online] :87 [viewed 17 November 2014] Available from: doi:10.1186/1471-2334-10-87
  16. FAREED MI, MAHMOUD AE. Spontaneous rupture of falciparum malarial spleen presenting as hemoperitoneum, hemothorax, and hemoarthrosis Am J Case Rep [online] :405-408 [viewed 17 November 2014] Available from: doi:10.12659/AJCR.889382
  17. MACHADO SIQUEIRA A, LOPES MAGALHãES BM, CARDOSO MELO G, FERRER M, CASTILLO P, MARTIN-JAULAR L, FERNANDEZ-BECERRA C, ORDI J, MARTINEZ A, LACERDA MV, DEL PORTILLO HA. Spleen Rupture in a Case of Untreated Plasmodium vivax Infection PLoS Negl Trop Dis [online] , 6(12):e1934 [viewed 17 November 2014] Available from: doi:10.1371/journal.pntd.0001934
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  32. JOHNSON S, WILKINSON R, DAVIDSON RN. Tropical respiratory medicine. 4. Acute tropical infections and the lung. Thorax [online] 1994 Jul, 49(7):714-718 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC475066
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  35. GOYAL JP, MAKWANA AM. Comparison of Clinical Profile between P. vivax and P. falciparum Malaria in Children: A Tertiary Care Centre Perspective from India Malar Res Treat [online] 2014:132672 [viewed 17 November 2014] Available from: doi:10.1155/2014/132672
  36. MOXON CA, HEYDERMAN RS, WASSMER SC. Dysregulation of coagulation in cerebral malaria Mol Biochem Parasitol [online] 2009 Aug, 166(2-3):99-108 [viewed 17 November 2014] Available from: doi:10.1016/j.molbiopara.2009.03.006
  37. SARAVU K, DOCHERLA M, VASUDEV A, SHASTRY BA. Thrombocytopenia in vivax and falciparum malaria: an observational study of 131 patients in Karnataka, India Ann Trop Med Parasitol [online] 2011 Dec, 105(8):593-598 [viewed 17 November 2014] Available from: doi:10.1179/2047773211Y.0000000013
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  39. UNEKE CJ. Impact of Placental Plasmodium falciparum Malaria on Pregnancy and Perinatal Outcome in Sub-Saharan Africa: I: Introduction to Placental Malaria Yale J Biol Med [online] 2007 Jun, 80(2):39-50 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2140183
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  47. FROM: THE INDIAN SOCIETY OF CRITICAL CARE MEDICINE TROPICAL FEVER GROUP, SINGHI S, CHAUDHARY D, VARGHESE GM, BHALLA A, KARTHI N, KALANTRI S, PETER JV, MISHRA R, BHAGCHANDANI R, MUNJAL M, CHUGH TD, RUNGTA N. Tropical fevers: Management guidelines Indian J Crit Care Med [online] 2014 Feb, 18(2):62-69 [viewed 22 November 2014] Available from: doi:10.4103/0972-5229.126074
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Differential Diagnoses

Fact Explanation
Other types of malaria Other types of malaria are plasmodium vivax, plasmodium ovale and plasmodium malariae. pathophysiology of all malarial infections are common with some changes of the behaviour of various parasites. In plasmodium vivax and plasmodium ovale incubation period is 8-25 days, asexual phase is 48 hrs giving a tertian periodic fever pattern.Exo-erythrocytic cycle will persist as hypnozoites and relapses are common up to 2 years. In plasmodium malariae incubation period is 15-30 days, asexual phase is 72 hrs giving a quartan periodic fever pattern. hypnozoites will not present and recrudescence can occur many years later. other types of malaria sequestration will not present and complicatons are not much severe as plasmodium falciparum malaria. thick and thin blood film examination will helpful in differentiating the various types.[1]-[4]
Dengue infection Dengue infection need to be consider mainly in tropical countries as it also spread by mosquitoes. In simple uncomplicated dengue fever there will be only fever, severe headache, myelgia, arthralgia associated with leucopenia and thrombocytopenia. In complicated stages (eg: dengue haemorrhagic fever) there will be complications like severe thrombocytopenia with spontaneous bleeding, fluid leakage causing pleural effusion and ascites, hypovolaemic shock and hepatic encephalopathy. Dengyue antigen tests will useful in diagnosing and differentiating the condition from malaria[5]-[8].
Leptospirosis This is a common zoonotic disease (caused by rodents especially common rat) caused by leptospira interrogans. patient will develop fever, weakness, muscle pain and tenderness, severe headache and photopobia like symptoms. complications associated with the disease are aseptic meningitis, pulmonary syndrome and weil's disease causing fever, haemorrhages, jaundice and acute renal failure. Microscopic agglutination test will confirm te disease and differentiate it from malaria[9]-[12].
Other causes of haemolytic anaemia In malarial infection there is an extensive haemolytivc anaemia. So other causes of aemolytic anaemia need to be excluded:. Eg Hereditory causes- hereditory spherocytosis, G6PD deficiency, genetic abnormalities of haemoglobin Acquired causes- autoimmune haemolytic anaemia, drug induced haemolysis, red cell fragmentation syndrome, march haemoglobinuria, paroxysmal nocturnal haemoglobinuria [17]-[20]
septicaemia caused by systemic infections Septicaemia secondary to various infections like Urinary tract infections, pulmonary infections, wound infections, gastrointestinal tract infections and central nervous system infections can present with septic shock. These causes need to be excluded in a septic shock of a malaria patient[13]-[16].
Other causes of strokes In a patient with cerebral malaria other causes of cerebral hypoperfusion need to be consider like diabetes mellitus, hypertension, hyperlipidaema , connective tissue disorders like SLE, thrombotic thrombocytopenic purpura and congenital thrombophilic conditions[21]-[25].
Other causes of acute renal failure In a case of acute renal failure other causes need to be excludes. In a non septic, haemodynamically stable patient urinary tract obstruction, vascular occlusion( by trombi, drugs like ACEI), rapid progressive glomerulonephritis, drug induced and acute interstitial nephritis ( eg; drug induced, immune mediated, secondary to infections and toxins[26]-[29].
References
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  19. KOK VC, LEE CK, HORNG JT, LIN CC, SUNG FC. Reappraisal of the Etiology of Extracorpuscular Non-Autoimmune Acquired Hemolytic Anemia in 2657 Hospitalized Patients with Non-Neoplastic Disease Clin Med Insights Pathol [online] :11-14 [viewed 25 November 2014] Available from: doi:10.4137/CPath.S14875
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  29. PHAM AQ, SCARLINO C. Diphenhydramine and Acute Kidney Injury P T [online] 2013 Aug, 38(8):453-461 [viewed 25 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3814442

Investigations - for Diagnosis

Fact Explanation
Full blood count This will give evidence of anaemia with low haemoglobin levels, WBC count will be important in a case of super added infection and Platelet count assessment will needed in the presence of spontaneous bleeding[1][2][3][7].
Thick and thin blood films Thick blood film- will show lysed red blood cells and useful in identifying the level of parasitaemia. Thin blood film is important in diagnosing the type of malaria according to the stages and number of stages available. in early stages of the plasmodium falciparum malaria there will be only ring forms and gametocytes appear after 2 weeks (they will persist even after treatments).[7]-[12]
Rapid stick test This an immunochromatographic test for plasmodium falciparum malaria antigens. This test is rapid and diagnose the disease with out microscopic look. But the test is 100 times less sensitive than a careful blood film examination.[4][5][6][13][14]
References
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  2. RIHET P, TRAORé Y, ABEL L, AUCAN C, TRAORé-LEROUX T, FUMOUX F. Malaria in humans: Plasmodium falciparum blood infection levels are linked to chromosome 5q31-q33. Am J Hum Genet [online] 1998 Aug, 63(2):498-505 [viewed 25 November 2014] Available from: doi:10.1086/301967
  3. JAIRAJPURI ZS, RANA S, HASSAN MJ, NABI F, JETLEY S. An Analysis of Hematological Parameters as a Diagnostic test for Malaria in Patients with Acute Febrile Illness: An Institutional Experience Oman Med J [online] 2014 Jan, 29(1):12-17 [viewed 25 November 2014] Available from: doi:10.5001/omj.2014.04
  4. MOODY A. Rapid Diagnostic Tests for Malaria Parasites Clin Microbiol Rev [online] 2002 Jan, 15(1):66-78 [viewed 25 November 2014] Available from: doi:10.1128/CMR.15.1.66-78.2002
  5. A rapid dipstick antigen capture assay for the diagnosis of falciparum malaria. WHO Informal Consultation on Recent Advances in Diagnostic Techniques and Vaccines for Malaria. Bull World Health Organ [online] 1996, 74(1):47-54 [viewed 25 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2486846
  6. UGUEN C, RABODONIRINA M, DE PINA JJ, VIGIER JP, MARTET G, MARET M, PEYRON F. ParaSight-F rapid manual diagnostic test of Plasmodium falciparum infection. Bull World Health Organ [online] 1995, 73(5):643-649 [viewed 25 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2486810
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  8. PASRICHA JM, JUNEJA S, MANITTA J, WHITEHEAD S, MAXWELL E, GOH WK, PASRICHA SR, EISEN DP. Is Serial Testing Required to Diagnose Imported Malaria in the Era of Rapid Diagnostic Tests? Am J Trop Med Hyg [online] 2013 Jan 9, 88(1):20-23 [viewed 25 November 2014] Available from: doi:10.4269/ajtmh.2012.11-0674
  9. BEJON P, ANDREWS L, HUNT-COOKE A, SANDERSON F, GILBERT SC, HILL AV. Thick blood film examination for Plasmodium falciparum malaria has reduced sensitivity and underestimates parasite density Malar J [online] :104 [viewed 25 November 2014] Available from: doi:10.1186/1475-2875-5-104
  10. CICERON L, JAUREGUIBERRY G, GAY F, DANIS M. Development of a Plasmodium PCR for Monitoring Efficacy of Antimalarial Treatment J Clin Microbiol [online] 1999 Jan, 37(1):35-38 [viewed 25 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC84160
  11. LEKE RF, DJOKAM RR, MBU R, LEKE RJ, FOGAKO J, MEGNEKOU R, METENOU S, SAMA G, ZHOU Y, CADIGAN T, PARRA M, TAYLOR DW. Detection of the Plasmodium falciparum Antigen Histidine-Rich Protein 2 in Blood of Pregnant Women: Implications for Diagnosing Placental Malaria J Clin Microbiol [online] 1999 Sep, 37(9):2992-2996 [viewed 25 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC85431
  12. HäNSCHEID T, VALADAS E, GROBUSCH MP. Polymerase Chain Reaction for Screening Blood Donors at Risk for Malaria: Safe and Useful? Emerg Infect Dis [online] 2002 Aug, 8(8):872 [viewed 25 November 2014] Available from: doi:10.3201/eid0808.020025
  13. PALMER CJ, BONILLA JA, BRUCKNER DA, BARNETT ED, MILLER NS, HASEEB MA, MASCI JR, STAUFFER WM. Multicenter Study To Evaluate the OptiMAL Test for Rapid Diagnosis of Malaria in U.S. Hospitals J Clin Microbiol [online] 2003 Nov, 41(11):5178-5182 [viewed 25 November 2014] Available from: doi:10.1128/JCM.41.11.5178-5182.2003
  14. PALMER CJ, LINDO JF, KLASKALA WI, QUESADA JA, KAMINSKY R, BAUM MK, AGER AL. Evaluation of the OptiMAL Test for Rapid Diagnosis of Plasmodium vivax and Plasmodium falciparum Malaria J Clin Microbiol [online] 1998 Jan, 36(1):203-206 [viewed 25 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC124834

Investigations - Fitness for Management

Fact Explanation
Blood grouping and cross matching As these patients can develop severe anaemia blood grouping and cross matching will be needed in a case of blood tramnsfusion[1][2][3].
Clotting profile with PT/INR and APTT As these patients are at risk of developing spontaneous bleeding and coagulopathy clotting profile useful in identifying the clotting defects[4]-[7].
Renal function tests like UFR, serum creatinine, blood urea and serum electrolytes Renal function assessment is useful in these patients as they are at risk of going in to acute renal failure.So there tests are useful in diagnosing as well as during the follow up[8]-[13].
Liver function tests like AST, ALT, Serum proteins, direct and indirect bilirubin levels At the beginning of the malarial infection in primary exo-eruthrocytic cycle parasites are multiply with in hepatocytes so liver cells can rupture and die with the release of merozoites. So assessment of liver funcction is important. With the excessive red cell destruction patient can develop jaundice causing increased unconjugated bilirubin. So assessment of bilirubin level and type (direct/ indirect) will be useful. With the excessive workload on liver, production of protein will be affected. So serum protein level will give a rough idea about the compromised function of the liver[14]-[17].
Random blood glucose level For early Hypoglycaemia identification will help in management. Capillary blood sugar level assessment can be done during continuous monitoring of the patient[18]-[22].
Arterial blood gas analysis This is useful in a suspected case of metabolic acidosis[23]-[27].
Blood/ urine culture and ABST In clinically suspected septicaemia these are useful before starting antibiotics[4][28][29][30].
Ultrasound scan In the presence of hepatosplenomegaly ultrasound scan of the abdomen will be useful[41][42][43]. Also antenatal ultrasouns scan with doppler will useful in pregnant patients to assess the foetal well being and the placental condition[44][45][46][47].
Chest X ray As these patients are at risk of developing pulmonary oedema, ARDS and aspiration pneumonia with development of cerebral malaria Chest X ray is useful[31]-[37].
CT/ MRI brain In cerebral malatria these are useful in diagnosing and managing the patient[23][38][39][40].
References
  1. GOSLING RD, HSIANG MS. Malaria and Severe Anemia: Thinking beyond Plasmodium falciparum PLoS Med [online] 2013 Dec, 10(12):e1001576 [viewed 22 November 2014] Available from: doi:10.1371/journal.pmed.1001576
  2. HALDAR K, MOHANDAS N. Malaria, erythrocytic infection, and anemia Hematology Am Soc Hematol Educ Program [online] 2009:87-93 [viewed 22 November 2014] Available from: doi:10.1182/asheducation-2009.1.87
  3. UNEKE CJ. Impact of Placental Plasmodium falciparum Malaria on Pregnancy and Perinatal Outcome in Sub-Saharan Africa: Part III: Placental Malaria, Maternal Health, and Public Health Yale J Biol Med [online] 2008 Mar, 81(1):1-7 [viewed 22 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442721
  4. MOXON CA, HEYDERMAN RS, WASSMER SC. Dysregulation of coagulation in cerebral malaria Mol Biochem Parasitol [online] 2009 Aug, 166(2-3):99-108 [viewed 17 November 2014] Available from: doi:10.1016/j.molbiopara.2009.03.006
  5. SARAVU K, DOCHERLA M, VASUDEV A, SHASTRY BA. Thrombocytopenia in vivax and falciparum malaria: an observational study of 131 patients in Karnataka, India Ann Trop Med Parasitol [online] 2011 Dec, 105(8):593-598 [viewed 17 November 2014] Available from: doi:10.1179/2047773211Y.0000000013
  6. GUPTA NK, BANSAL SB, JAIN UC, SAHARE K. Study of thrombocytopenia in patients of malaria Trop Parasitol [online] 2013, 3(1):58-61 [viewed 17 November 2014] Available from: doi:10.4103/2229-5070.113914
  7. POOVATHINGAL MA, NAGIRI SK, NAGARAJA. The emerging trends of falciparum malaria: a study from a tertiary centre in an endemic area of India Asian Pac J Trop Biomed [online] 2014 May, 4(Suppl 1):S81-S86 [viewed 22 November 2014] Available from: doi:10.12980/APJTB.4.2014C1139
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  9. MEREMO AJ, KILONZO SB, MUNISI D, KAPINGA J, JUMA M, MWANAKULYA S, MPONDO B. Acute renal failure in a Caucasian traveler with severe malaria: a case report Clin Case Rep [online] 2014 Jun, 2(3):82-85 [viewed 17 November 2014] Available from: doi:10.1002/ccr3.65
  10. RAFIEIAN-KOPAEI M, NASRI H, ALIZADEH F, ATAEI B, BARADARAN A. Immunoglobulin A Nephropathy and Malaria falciparum Infection; a Rare Association Iran J Public Health [online] , 42(5):529-533 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684463
  11. FRY AC, FARRINGTON K. Management of acute renal failure Postgrad Med J [online] 2006 Feb, 82(964):106-116 [viewed 22 November 2014] Available from: doi:10.1136/pgmj.2005.038588
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  13. VIRIYAVEJAKUL P, KHACHONSAKSUMET V, PUNSAWAD C. Liver changes in severe Plasmodium falciparum malaria: histopathology, apoptosis and nuclear factor kappa B expression Malar J [online] :106 [viewed 25 November 2014] Available from: doi:10.1186/1475-2875-13-106
  14. GOYAL JP, MAKWANA AM. Comparison of Clinical Profile between P. vivax and P. falciparum Malaria in Children: A Tertiary Care Centre Perspective from India Malar Res Treat [online] 2014:132672 [viewed 25 November 2014] Available from: doi:10.1155/2014/132672
  15. SAYA RP, DEBABRATA G, SAYA GK. Malarial Hepatopathy and Its Outcome in India N Am J Med Sci [online] 2012 Oct, 4(10):449-452 [viewed 17 November 2014] Available from: doi:10.4103/1947-2714.101981
  16. ZUBAIRI AB, NIZAMI S, RAZA A, MEHRAJ V, RASHEED AF, GHANCHI NK, KHALED ZN, BEG MA. Severe Plasmodium vivax Malaria in Pakistan Emerg Infect Dis [online] 2013 Nov, 19(11):1851-1854 [viewed 17 November 2014] Available from: doi:10.3201/eid1911.130495
  17. ALEXANDRE MA, FERREIRA CO, SIQUEIRA AM, MAGALHãES BL, MOURãO MP, LACERDA MV, ALECRIM MD. Severe Plasmodium vivax Malaria, Brazilian Amazon Emerg Infect Dis [online] 2010 Oct, 16(10):1611-1614 [viewed 17 November 2014] Available from: doi:10.3201/eid1610.100685
  18. MISHRA SK, NEWTON CR. Diagnosis and management of the neurological complications of falciparum malaria Nat Rev Neurol [online] 2009 Apr, 5(4):189-198 [viewed 25 November 2014] Available from: doi:10.1038/nrneurol.2009.23
  19. ABDALLAH TM, ABDEEN MT, AHMED IS, HAMDAN HZ, MAGZOUB M, ADAM I. Severe Plasmodium falciparum and Plasmodium vivax malaria among adults at Kassala Hospital, eastern Sudan Malar J [online] :148 [viewed 25 November 2014] Available from: doi:10.1186/1475-2875-12-148
  20. ODEH M. Falciparum malaria and hypoglycaemia. Postgrad Med J [online] 1993 Apr, 69(810):325 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2399664
  21. ATABANI GS, SAEED BO, ELSEED BA, BAYOUMI MA, HADI NH, ABU-ZEID YA, BAYOUMI RA. Hypoglycaemia in Sudanese children with cerebral malaria. Postgrad Med J [online] 1990 Apr, 66(774):326-327 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2429396
  22. SHALEV O, TSUR A, RAHAV G. Falciparum malaria-induced hypoglycaemia in a diabetic patient. Postgrad Med J [online] 1992 Apr, 68(798):281-282 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2399263
  23. IDRO R, MARSH K, JOHN CC, NEWTON CR. Cerebral Malaria; Mechanisms Of Brain Injury And Strategies For Improved Neuro-Cognitive Outcome Pediatr Res [online] 2010 Oct, 68(4):267-274 [viewed 17 November 2014] Available from: doi:10.1203/PDR.0b013e3181eee738
  24. JOHN CC, KUTAMBA E, MUGARURA K, OPOKA RO. Adjunctive therapy for cerebral malaria and other severe forms of Plasmodium falciparum malaria Expert Rev Anti Infect Ther [online] 2010 Sep, 8(9):997-1008 [viewed 17 November 2014] Available from: doi:10.1586/eri.10.90
  25. ZOUGBéDé S, MILLER F, RAVASSARD P, REBOLLO A, CICéRON L, COURAUD PO, MAZIER D, MORENO A. Metabolic acidosis induced by Plasmodium falciparum intraerythrocytic stages alters blood-brain barrier integrity J Cereb Blood Flow Metab [online] 2011 Feb, 31(2):514-526 [viewed 17 November 2014] Available from: doi:10.1038/jcbfm.2010.121
  26. ACKERMAN H. Management of severe malaria: Enthusiasm for fluid resuscitation dampened by lung water Crit Care Med [online] 2013 Apr, 41(4):1139-1140 [viewed 17 November 2014] Available from: doi:10.1097/CCM.0b013e318283cab1
  27. KOCHAR DK, TANWAR GS, KHATRI PC, KOCHAR SK, SENGAR GS, GUPTA A, KOCHAR A, MIDDHA S, ACHARYA J, SAXENA V, PAKALAPATI D, GARG S, DAS A. Clinical Features of Children Hospitalized with Malaria—A Study from Bikaner, Northwest India Am J Trop Med Hyg [online] 2010 Nov 5, 83(5):981-989 [viewed 25 November 2014] Available from: doi:10.4269/ajtmh.2010.09-0633
  28. FILIPE EM, ANTUNES L, TOMáS EF, VIEGAS E, BERNARDO J, SILVA FR. Comparing severity between Plasmodium falciparum malaria and sepsis Malar J [online] , 9(Suppl 2):P10 [viewed 25 November 2014] Available from: doi:10.1186/1475-2875-9-S2-P10
  29. PANDA M, SAHOO PK, MOHAPATRA AD, DUTTA SK, THATOI PK, TRIPATHY R, DAS BK, SATPATHY AK, RAVINDRAN B. Decreased prevalence of sepsis but not mild or severe P. falciparum malaria is associated with pre-existing filarial infection Parasit Vectors [online] :203 [viewed 25 November 2014] Available from: doi:10.1186/1756-3305-6-203
  30. CHURCH J, MAITLAND K. Invasive bacterial co-infection in African children with Plasmodium falciparum malaria: a systematic review BMC Med [online] :31 [viewed 25 November 2014] Available from: doi:10.1186/1741-7015-12-31
  31. MARCHIORI E, ZANETTI G, HOCHHEGGER B, CANELLA C, IRION KL. Plasmodium falciparum malaria: another infection of interest to pulmonologists J Bras Pneumol [online] 2013, 39(6):750-752 [viewed 25 November 2014] Available from: doi:10.1590/S1806-37132013000600015
  32. MARCHIORI E, ZANETTI G, HOCHHEGGER B, CANELLA C, IRION KL. Plasmodium falciparum malaria: another infection of interest to pulmonologists J Bras Pneumol [online] 2013, 39(6):750-752 [viewed 25 November 2014] Available from: doi:10.1590/S1806-37132013000600015
  33. SARKAR S, SAHA K, DAS CS. Three cases of ARDS: An emerging complication of Plasmodium vivax malaria Lung India [online] 2010, 27(3):154-157 [viewed 25 November 2014] Available from: doi:10.4103/0970-2113.68323
  34. JOHNSON S, WILKINSON R, DAVIDSON RN. Tropical respiratory medicine. 4. Acute tropical infections and the lung. Thorax [online] 1994 Jul, 49(7):714-718 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC475066
  35. MARTELL RW, KALLENBACH J, ZWI S. Pulmonary oedema in the falciparum malaria. Br Med J [online] 1979 Jun 30, 1(6180):1763-1764 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1599415
  36. TRAMPUZ A, JEREB M, MUZLOVIC I, PRABHU RM. Clinical review: Severe malaria Crit Care [online] 2003, 7(4):315-323 [viewed 17 November 2014] Available from: doi:10.1186/cc2183
  37. GOYAL JP, MAKWANA AM. Comparison of Clinical Profile between P. vivax and P. falciparum Malaria in Children: A Tertiary Care Centre Perspective from India Malar Res Treat [online] 2014:132672 [viewed 17 November 2014] Available from: doi:10.1155/2014/132672
  38. RASALKAR DD, PAUNIPAGAR BK, SANGHVI D, SONAWANE BD, LONIKER P. Magnetic resonance imaging in cerebral malaria: a report of four cases Br J Radiol [online] 2011 Apr, 84(1000):380-385 [viewed 25 November 2014] Available from: doi:10.1259/bjr/85759874
  39. MAUDE RJ, BARKHOF F, HASSAN MU, GHOSE A, HOSSAIN A, ABUL FAIZ M, CHOUDHURY E, RASHID R, SAYEED AA, CHARUNWATTHANA P, PLEWES K, KINGSTON H, MAUDE RR, SILAMUT K, DAY NP, WHITE NJ, DONDORP AM. Magnetic resonance imaging of the brain in adults with severe falciparum malaria Malar J [online] :177 [viewed 25 November 2014] Available from: doi:10.1186/1475-2875-13-177
  40. MOHANTY S, TAYLOR TE, KAMPONDENI S, POTCHEN MJ, PANDA P, MAJHI M, MISHRA SK, WASSMER SC. Magnetic resonance imaging during life: the key to unlock cerebral malaria pathogenesis? Malar J [online] :276 [viewed 25 November 2014] Available from: doi:10.1186/1475-2875-13-276
  41. WILSON S, JONES FM, MWATHA JK, KIMANI G, BOOTH M, KARIUKI HC, VENNERVALD BJ, OUMA JH, MUCHIRI E, DUNNE DW. Hepatosplenomegaly associated with chronic malaria exposure: evidence for a pro-inflammatory mechanism exacerbated by schistosomiasis Parasite Immunol [online] 2009 Feb, 31(2):64-71 [viewed 17 November 2014] Available from: doi:10.1111/j.1365-3024.2008.01078.x
  42. WILSON S, VENNERVALD BJ, DUNNE DW. Chronic Hepatosplenomegaly in African School Children: A Common but Neglected Morbidity Associated with Schistosomiasis and Malaria PLoS Negl Trop Dis [online] , 5(8):e1149 [viewed 17 November 2014] Available from: doi:10.1371/journal.pntd.0001149
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  45. UNEKE CJ. Impact of Placental Plasmodium falciparum Malaria on Pregnancy and Perinatal Outcome in Sub-Saharan Africa: I: Introduction to Placental Malaria Yale J Biol Med [online] 2007 Jun, 80(2):39-50 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2140183
  46. UNEKE CJ. Impact of Placental Plasmodium falciparum Malaria on Pregnancy and Perinatal Outcome in Sub-Saharan Africa: Part III: Placental Malaria, Maternal Health, and Public Health Yale J Biol Med [online] 2008 Mar, 81(1):1-7 [viewed 17 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442721
  47. ROWE JA, KYES SA. The role of Plasmodium falciparum var genes in malaria in pregnancy Mol Microbiol [online] 2004 Aug, 53(4):1011-1019 [viewed 17 November 2014] Available from: doi:10.1111/j.1365-2958.2004.04256.x

Investigations - Followup

Fact Explanation
In the follow up continuing the same investigations mentioned in the fitness assessment will be helpful. In follow up also regular full blood count capillary blood sugar monitoring, renal function tests, liver function tests, serial ultrasound scans with doppler in anteneatal follow ups, Chest Xray will be useful.
References

Management - General Measures

Fact Explanation
Health education Educate the patient and family members about the disease, possible complications, investigations which need to be done, treatments available, way of spreading, importance of prophylaxis and prevention[1][2][3][4].
Prevention 1) Avoid mosquito bites is one of measure to prevent the disease. wearing long sleeves and trousers to especially at night (time of anopheline mosquito bites), use of mosquito repellents like mosquito coils, sprays, creams and so on and use of mosquito nets will help in aviding mosquito bites[5][6][7]. 2) Control mosquitoes is another method and can be done in community level in endemic areas. eg; Destroying mosquito breading places Destroy mosquitoes with chemicals (eg; permethrine) Biological control of early stages with special fish species. [8][9][10] 3) Chemoprophylaxis can be use to prevent the disease occurrence. eg; Proguanil- useful in pre erythrocytic forms Atovaquone with Proguanil/ doxycycline/ chloroquine/ mefloquine - useful in erythrocytic stage The choice of drug and doses will be depend on living area/ traveling area, length of exposure, level of disease transmission, drug resistance, presence of any underlying disease and medications currently on.[11]-[14]
Close monitoring patient's vital parameters like temperature, blood pressure, pulse rate, respiratory rate, urine out put need to be monitor. Maintaining a temperature chart and input output chart will be more useful.[47][48]
Antipyretics Antipyretics like paracetamol, ibuprofen will be useful in controlling the fever. Other than that measures like tepid sponging and fanning will also useful[15]-[19]
Exchange transfusion in severe disease Exchange transfusion will be useful in reducing the parasitic load and infected red blood cells[23]-[26].
Blood transfusion for severe anaemia Blood transfusion can be consider according to the haemoglobin level and the anemic symptoms of the poatient in severe disease[20][21][22].
Management of acute renal failure Main thing is to start antimalarial treatment then symptomatic management can be done to protect the renal function. Monitoring the fluid balance, fluid replacement combine with diuretics/ dopamine and if serum creatinine level is high/ hyperkalaemia features present dialysis can be consider. [31]-[35]
Management of respiratory complications like pulmonary oedema and ARDS In pulmonary oedema prop up the patient in 45 degree angle, give oxygen, stop IV infusions and use IV diuretics and intubate is hypoxia is severe. In ARDS ITU admission, supportive therapy (respiratory support- eg: CPAP, circulatory support- eg; fluid management, inotropes) and specific treatment for underlying cause are the main treatment options.[36]-[39]
Management of shock Secure ABC, give high flow oxygen, establish two IV accesses with wide bore cannulas, send blood for investigatins to identify the causative factors and rapid fluid infusion will be needed to secure haemadynamic stability. Identify and treat the primary cause as soon as possible.[40]-[46]
Management of hypoglycaemia As mentioned in the history hypoglycaemia occur in severe disease and with quinine therapy. So people who are at risk of developing hypoglycaemia must educate about the risk, symptoms and first aid. CBS need to monitor frequently for early identification. Management of hypoglycaemia: Give oral dextrose to replace the deficiency. Management of hypoglycaemic coma: Give IV 20-30g dextrose, If not recovering can give IV/IM glucagon 1mg. Dextrose IV infusion will be useful in prolonged hypoglycaema.[27]-[30]
Management of metabolic acidosis Give oxygen. Look for the primary cause (hypoglycaemia/ hypovolaemia/ septicaemia) and treat it.[49]-[52]
Management of spontaneous bleeding and coagulopathy Transfusion of FFP/ cryoprecipitate and platelets will be useful in spontaneous bleeding. Vitamin K injection will also be useful.[53]-[56]
References
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  2. GHAHREMANI L, FARYABI R, KAVEH MH. Effect of Health Education Based on the Protection Motivation Theory on Malaria Preventive Behaviors in Rural Households of Kerman, Iran Int J Prev Med [online] 2014 Apr, 5(4):463-471 [viewed 22 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4018595
  3. TOBGAY T, PEM D, DOPHU U, DUMRE SP, NA-BANGCHANG K, TORRES CE. Community-directed educational intervention for malaria elimination in Bhutan: quasi-experimental study in malaria endemic areas of Sarpang district Malar J [online] :132 [viewed 22 November 2014] Available from: doi:10.1186/1475-2875-12-132
  4. SALAM RA, DAS JK, LASSI ZS, BHUTTA ZA. Impact of community-based interventions for the prevention and control of malaria on intervention coverage and health outcomes for the prevention and control of malaria Infect Dis Poverty [online] :25 [viewed 22 November 2014] Available from: doi:10.1186/2049-9957-3-25
  5. HARTJES LB. Preventing and Detecting Malaria Infections Nurse Pract [online] 2011 Jun, 36(6):45-53 [viewed 22 November 2014] Available from: doi:10.1097/01.NPR.0000397912.05693.20
  6. ONYENEHO NG. Sleeping under Insecticide-treated Nets to Prevent Malaria in Nigeria: What Do We Know? J Health Popul Nutr [online] 2013 Jun, 31(2):243-251 [viewed 22 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3702346
  7. DURRHEIM DN, LEGGAT PA. Prophylaxis against malaria : Preventing mosquito bites is also effective BMJ [online] 1999 Apr 24, 318(7191):1139 [viewed 22 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1115531
  8. CURTIS CF. Malaria control through anti-mosquito measures. J R Soc Med [online] 1989, 82(Suppl 17):18-22 [viewed 22 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1291932
  9. HARTJES LB. Preventing and Detecting Malaria Infections Nurse Pract [online] 2011 Jun, 36(6):45-53 [viewed 22 November 2014] Available from: doi:10.1097/01.NPR.0000397912.05693.20
  10. KILLEEN GF, SMITH TA, FERGUSON HM, MSHINDA H, ABDULLA S, LENGELER C, KACHUR SP. Preventing Childhood Malaria in Africa by Protecting Adults from Mosquitoes with Insecticide-Treated Nets PLoS Med [online] 2007 Jul, 4(7):e229 [viewed 22 November 2014] Available from: doi:10.1371/journal.pmed.0040229
  11. KRAUSE G, SCHöNEBERG I, ALTMANN D, STARK K. Chemoprophylaxis and Malaria Death Rates Emerg Infect Dis [online] 2006 Mar, 12(3):447-451 [viewed 22 November 2014] Available from: doi:10.3201/eid1203.050736
  12. WETSTEYN JC, DE GEUS A. Comparison of three regimens for malaria prophylaxis in travellers to east, central, and southern Africa. BMJ [online] 1993 Oct 23, 307(6911):1041-1043 [viewed 22 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1679243
  13. SCHLAGENHAUF P, PETERSEN E. Malaria Chemoprophylaxis: Strategies for Risk Groups Clin Microbiol Rev [online] 2008 Jul, 21(3):466-472 [viewed 22 November 2014] Available from: doi:10.1128/CMR.00059-07
  14. DIARA M, NOWOSIWSKY A, HARMEN S, BURKE N, ALILIO M. Enabling Factors for Improved Malaria Chemoprophylaxis Compliance Am J Trop Med Hyg [online] 2012 Nov 7, 87(5):960-961 [viewed 22 November 2014] Available from: doi:10.4269/ajtmh.2012.12-0277c
  15. MATSIéGUI PB, MISSINOU MA, NECEK M, MAVOUNGOU E, ISSIFOU S, LELL B, KREMSNER PG. Antipyretic effect of ibuprofen in Gabonese children with uncomplicated falciparum malaria: a randomized, double-blind, placebo-controlled trial Malar J [online] :91 [viewed 22 November 2014] Available from: doi:10.1186/1475-2875-7-91
  16. KRUDSOOD S, TANGPUKDEE N, WILAIRATANA P, POTHIPAK N, DUANGDEE C, WARRELL DA, LOOAREESUWAN S. Intravenous Ibuprofen (IV-ibuprofen) Controls Fever Effectively in Adults with Acute Uncomplicated Plasmodium falciparum Malaria but Prolongs Parasitemia Am J Trop Med Hyg [online] 2010 Jul, 83(1):51-55 [viewed 22 November 2014] Available from: doi:10.4269/ajtmh.2010.09-0621
  17. GODSE KV, ZAWAR V. Malaria Presenting as Urticaria Indian J Dermatol [online] 2012, 57(3):237-238 [viewed 17 November 2014] Available from: doi:10.4103/0019-5154.96213
  18. DURAND R, PRENDKI V, CAILHOL J, HUBERT V, RALAIMAZAVA P, MASSIAS L, BOUCHAUD O, LE BRAS J. Plasmodium falciparum Malaria and Atovaquone-Proguanil Treatment Failure Emerg Infect Dis [online] 2008 Feb, 14(2):320-322 [viewed 17 November 2014] Available from: doi:10.3201/eid1402.070945
  19. MCCARRA MB, AYODO G, SUMBA PO, KAZURA JW, MOORMANN AM, NARUM DL, JOHN CC. Antibodies to Plasmodium Falciparum Erythrocyte Binding Antigen-175 are Associated with Protection from Clinical Malaria Pediatr Infect Dis J [online] 2011 Dec, 30(12):1037-1042 [viewed 17 November 2014] Available from: doi:10.1097/INF.0b013e31822d1451
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Management - Specific Treatments

Fact Explanation
Uncomplicated Plasmodium falciparum malarial management oral Quinine dihydrochloride/ sulphate 600mg (10mg/Kg) 8hrly for 3-5 days until clinical improvement with blood free from parasites. This should be followed by a single dose of sulfadoxine 1.5mg combine with pyrimethamine 75mg. Other combinations available are (in case of decreased quinine efficasy), 1) Atovaquone 250mg with proguanil 100mg 4 tablets once daily for 3 days 2) oral artemether200mg daily for 5 days followed by mefloquine 500mg 2 doses 2 hours apart 3) Oral artemether 80/480 mg twice a day for 3 days [1]-[4]
Cerebral malaria management Patient should be admitted to ITU and monitoring need to be done while managing associated complications (eg: giving diazepam for seizures). proper antimalarial treatment should be included from below options, 1) Antimal Artesunate/ quinine 20mg/kg (maximum 1.4g) over 4 hours every 8 hourly (or can be given as an IVI of 30mg/kg/day after loading dose) 2) Artemether 3.2mg/Kg followed by 1.6mg/Kg daily. [5][10][11]
Malaria management in pregnancy quinine alone for 7 days need to be given. If needed doxycycline 100mg daily for 7 days can be added.[6]-[9]
References
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  5. IDRO R, MARSH K, JOHN CC, NEWTON CR. Cerebral Malaria; Mechanisms Of Brain Injury And Strategies For Improved Neuro-Cognitive Outcome Pediatr Res [online] 2010 Oct, 68(4):267-274 [viewed 22 November 2014] Available from: doi:10.1203/PDR.0b013e3181eee738
  6. UNEKE CJ. Impact of Placental Plasmodium falciparum Malaria on Pregnancy and Perinatal Outcome in Sub-Saharan Africa: I: Introduction to Placental Malaria Yale J Biol Med [online] 2007 Jun, 80(2):39-50 [viewed 25 November 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2140183
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  11. MAITLAND K, NADEL S, POLLARD AJ, WILLIAMS TN, NEWTON CR, LEVIN M. Management of severe malaria in children: proposed guidelines for the United Kingdom BMJ [online] 2005 Aug 6, 331(7512):337-343 [viewed 25 November 2014] Available from: doi:10.1136/bmj.331.7512.337