CLINICAL FEATURES OF MALARIA

  • It may be asymptomatic, mild illness (uncomplicated malaria) or severe illness (severe malaria)
  • Intermittent fever is the most characteristic symptom of malaria. Three classical stages can be distinguished in a typical attack of malaria:
    • The cold stage: the patient feels cold and shivers
    • The hot stage: the patient feels hot
    • The sweating stage: associated with sweating and relief of symptoms
  • A complete physical examination has to be performed in any patient presenting with fever or history of fever
  • When people are frequently exposed to malaria, they develop partial immunity. In such people, the classical stages of a malaria attack above may not be observed
  • Also, in people who have had partial treatment with antimalarial medicines, these classical stages may not be pronounced

Uncomplicated Malaria

Common symptoms/signs of uncomplicated malaria

  • Fever: above 37.5°C (taken from the axilla ) or history of fever
  • Loss of appetite, mild vomiting, diarrhoea
  • Weakness, headache, joint and muscle pain
  • Mild anaemia (mild pallor of palms and mucous membranes); occurs commonly in children
  • Mild dehydration (dry mouth, coated tongue, and sunken eyes). In adults,  sunken eyes are usually a sign of severe dehydration
  • Enlarged spleen (in acute malaria it may be minimally enlarged, soft and mildly tender)

Complicated/Severe Malaria

It is an immediate threat to life and is therefore a medical emergency. Malaria is regarded as severe if there are asexual forms of P. falciparum in blood plus one or more of the following complications in the table below.

Classical definition of severe malaria

Severe dehydration Sunken eyes, coated tongue, lethargy,
inability to drink

COMPLICATION CRITERION FOR DIAGNOSIS
Defining manifestations
Cerebral malaria Deep coma (unable to localise a
painful stimulus), Normal CSF,
parasitaemia
Severe anaemia Hb <5g/dl with parasitaemia
(<7 g/dl in pregnancy)
Respiratory
distress
Tachypnoea, nasal flaring and
intercostal recession in a patient with
parasitaemia
Hypoglycaemia Blood glucose <40 mg/dl
(2.2 mmol/L) with parasitaemia
Circulatory
collapse
Clinical shock (systolic pressure <50
mmHg for children and <80mmHg for
adults, with cold peripheries, clammy
skin) with parasitaemia
Renal failure Urine output < 12 ml/kg in 24 hours and plasma creatinine > 3.0 mg/dl,
with parasitaemia
Spontaneous
bleeding
Parasitaemia with unexplained
spontaneous bleeding
(haematemesis, melaena, or
prolonged bleeding from nose, gum or
venipuncture site
Repeated
convulsions
2 or more convulsions in 24 hours,
with parasitaemia
Acidosis Deep (acidotic) breathing and plasma
bicarbonate <15 mmol/L, with
parasitaemia
Haemoglobinuria Parasitaemia, haemoglobin in urine
(dark coloured urine but no RBC’s)
Pulmonary
Oedema
Deep breathing, fast breathing,
laboured breathing (nasal flaring,
intercostal recession and chest indrawing),
Cheyne stokes breathing
Supporting manifestations (some other signs in
addition to above complications)
Impaired
consciousness
Parasitaemia with depressed level
of consciousness but can localize
a painful stimulus, or change of
behavior, confusion, drowsiness
Jaundice Parasitaemia with unexplained
jaundice
Prostration Unable to sit, in a child normally able
to do so or unable to drink in one too
young to sit
Severe vomiting Vomiting everything, not able to drink
or breastfeed
Hyperpyrexia Temperature >39.50 C, with
parasitaemia
Hyperparasitaemia Parasite count > 250,000 /μl, > 10%
Threatening
abortion
Uterine contractions and vaginal
bleeding