Malaria must be considered in any person who has traveled to the tropics and presents with an unexplained febrile illness. Five species of the protozoan Plasmodium infect humans: P falciparum, P vivax, P ovale, P malariae, and P knowlesi. The organism is transmitted by the anopheline mosquito bite and travels hematogenously first to the liver, where asexual reproduction occurs (exoerythrocytic stage). The liver cell ruptures, releasing merozoites that invade erythrocytes, multiply, and cause hemolysis (erythrocytic stage). Malaria also may be transmitted by blood transfusion or passed transplacentally from mother to fetus.
Malaria transmission occurs in large areas of Central and South America, the Caribbean, sub-Saharan Africa, the Indian subcontinent, Southeast Asia, the Middle East, and Oceania (New Guinea, Solomon Islands, etc). More than 50% of all the cases of malaria in the United States, including most cases due to P falciparum, arise from travel to sub-Saharan Africa. Resistance of P falciparum to chloroquine and other drugs continues to spread (see Table 95-1). Strains of P vivax with chloroquine resistance have been identified. The Centers for Disease Control and Prevention (CDC) has a malaria hotline: 770-488-7788 M-F, 8 am to 4:30 pm EST, and 770-488-7100 after hours, weekends and holidays. Alternatively, the CDC website can be accessed at http://www.cdc.gov/malaria/ for information on resistance patterns in various countries and information on malaria prophylaxis and treatment. When in doubt, chloroquine resistance for initial treatment should be assumed.
Table 95-1 Geographic Distribution of Malaria, Including Resistant Strains |Favorite Table|Download (.pdf)
Table 95-1 Geographic Distribution of Malaria, Including Resistant Strains
|Geographic Region||Areas With Malaria||Countries With Chloroquine-Resistant Plasmodium falciparum|
|Central America||All countries||Areas east of the Panama Canal|
|Caribbean||Dominican Republic and Haiti||None|
| Tropical||Most countries||All countries except Paraguay|
|Eastern South Asia||All countries except Brunei and Singapore||All infected areas|
|Middle South Asia||All countries||All countries|
|Western South Asia and Middle East||Iraq, Oman, Saudi Arabia, Syria, Turkey, and United Arab Emirates||All countries except Syria and Turkey|
|Northern Africa||All countries except Tunisia||None|
|Sub-Saharan Africa||All countries except Reunion and Seychelles||Widespread|
|Southern Africa||All countries except Lesotho and Saint Helena||Widespread|
|Oceania||Limited to Papua New Guinea, Solomon Islands, and Vanuatu (small foci elsewhere)||Widespread|
The incubation period ranges from 1 to 4 weeks. Partial chemoprophylaxis or incomplete immunity can prolong the incubation period to months or even years. Initially malaria manifests with nonspecific fever and malaise, then progresses to chills and high grade fevers; frequent symptoms include headache, myalgia, arthralgia, cough, abdominal pain, nausea, and diarrhea. The patient may have tachycardia, orthostatic dizziness, and extreme weakness. Classically, cycles of fever and chills followed by profuse diaphoresis and exhaustion occur at regular intervals, reflecting hemolysis of infected erythrocytes.
Physical examination findings are typically nonspecific. During a febrile paroxysm, most patients appear acutely ill, ...