Dr. Jayant Prakash*, Dr. Mani Bhushan**
Lecturer, PMCH, Patna.*, Junior Resident**
Malaria is an acute and chronic protozoal disease. It is caused by genus Plasmodium and transmitted to man by certain species of infected female anopheline. It is one of the most dreaded infections in tropical country. India is rightly claimed to be the cradle of modern malariology. Most deaths occur in infants and young children.

Clinical manifestations: There has been wide variation in sympmatology and presentations of cases of malaria depending on immunity status and age group.
In India, the most common species found is P. vivax (incidence rate 70%) having incubation period of 12-17 days. Next common species is P. falciparum (incidence rate 25-30) having incubation period of 9-14 days. In India P. malaria has a relatively low incidence (<1%) having incubation period 16-18 days is rarely found species.

Prodromal symptoms include non-specific conditions like generalized weakness, headache fatigue, abdominal discomfort and muscle ache, loss of appetite, nausea & vomiting followed by fever.

Classical presentation of malaria consists of paroxysms of chills and rigor (15 min. - 1 hr.) followed by hot stage (1-8 hr) then there is sweating stage (fever comes down with profuse sweating). By this typical presentation, malaria can be diagnosed easily even at peripheries. Generally there are no such typical characteristics of fever in children. In pediatric age, this intermittent pattern of fever is invariably absent but an irregular fever with respiratory or gastrointestinal symptoms may mark the disease. P. falciparum often presents with continuous fever may be absent in congenital and neonatal malaria.

Symptoms associated with febrile paroxysm include rigor, sweating and headache as well as myalgia, backache, abdominal pain, nausea, vomiting, diarrhea, pallor. On examination hepatosplenomegaly is also found. But splenomegaly may not present in case of P. falciparum infection.

Malaria may involve every organ hence symptoms and signs varied accordingly. Complications with which we usually concerned vary from common to rare ones.

CNS Manifestations: P. falciparum infection can present as frank cerebral malaria in which there is repeated convulsions (> 3 convulsions in 24 hour despite cooling) or unarousable, coma not attributable to any other cause, should persist at convulsion. But in case of P. vivax infection, changes in behaviour and level of sensorium can be observed. In children neurological sequelae occur more than 10%. Abnormality of brain stem reflexes (e.g., oculovestibular, oculocervical) may also found. Cranial nerve and meningeal sign remain absent.

Hematological: Mild anemia is very common but anemia may be very serve (presented with Hb <5 g/dl or Hct <15% in the presence of parasite count> 10,000/MCI) or even fatal, particularly when it is chronic and recurrent.

Mild decrease in platelet count can occur in P. vivax malaria. But in rare condition in P. falciparum infection abnormal bleeding and / DIC (spontaneous bleeding from rums, nose, GIT and / or substantial lab evidence) may develope.

Hypoglycemia: Whole blood glucose conc. < 40 mg/dl Hepatic Dysfunction - Hepatomelogy with or without jaundice (visible jaundice or S. bilirubin > 2.5 mg/dl) may be seen in severe malaria which mimic viral hepatitis.

Fluid, electrolyte and acid-base imbalance: Signs of dehydration, dyselectrolytemia and academia/acidosis (Arterial ph < 7.25 or plasma HCO3 < 15 mmol/l may be present

Macroscopic hemoglobinuria: Hemoglobinuria not secondary to G6PD deficiency.

Renal Involvement: In rare condition, there is renal failure (Presenting with urine output <12 ml/kg/24 hr. In children, failing to improve after re-hydration, creatinine>3 mg/dl). Urine volume usually resume in median 4 days and creatinine level come down to normal in a mean of 17 days. In very rare occasion, we also observed hematuria.
In areas where P. Malaria is predominate, patient may present by the age of 15 years with typical nephritic syndrome.

Pulmonary Oedema: Respiratory distress (Tachypnea, deep breathing/nasal flaring/intercostal in drawing) and/or radiological evidence of pulmonary oedema may also present in few cases.

Algid Malaria: there is circulatory collapse (Systolic BP <70 mm of Hg in older children, <50 mm of hg in 1-5 years with cold extremity, temperature difference> 10oC in case of severe P. falciparum infection.

Complicating or Associated infection: Aspiration pneumonia, bronchopneumonia, septicemia, urinary tract infection, etc.

Splenic Rupture: Malaria is an important cause for spontaneous rupture of spleen. It is more common in vivax malaria than falciparum malaria and tends to occur in up to 0.7% of the patient.

Neonatal Malaria or Congenital Malaria: It may present with progressive pallor and hepatosplenomegaly without fever. Congenital infection manifests within 2-3 weeks after birth whereas acquired infection presents at 4-6 weeks.
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