Complicated / Severe Falciparum
Malaria


The hallmark of Falciparum malaria is its severity and/or its complications. The various complications are :

1. Cerebral malaria
2. Anemia
3. Hypoglycemia
4. Acute renal failure
5. Pulmonary edema
6. Bleeding diathesis / DIC
7. Hemoglobinuria
8. Septicemia
9. Shock
10. Fluid, electrolyte and acid-base imbalance
11. Hyperparasitemia
12. Hyperpyrexia

Although general clinical features are same as adult malaria, there are certain special features in children especially below the age of 5 years. In hyperendemic areas, children below the age of 2 months do not develop malaria because they have immunity transferred from the mother.

Following table gives difference betweeen severe malaria in children and adults.

Signs / Symptoms	Adults	Children
Cough	Uncommon	Common
Convulsions	Common	Very common
Duration of illness	5-7 days	1-2 days
Resolution of coma	2-4 days	1-2 days
Neurological sequale	Less than 5%	More than 10%
Jaundice	Common	Uncommon
Pretreatment hypoglycemia	Uncommon	Common
Pulmonary edema	Common	Rare
Renal failure	Common	Rare
CSF opening pressure	Usually normal	Variable
Bleeding / clotting disturbances	Up to 10%	Rare
Abnormality of brain stem reflexes (e.g. oculovestibular, oculocervical)	Rare	More common

(Ref : WHO Booklet)

Two important chronic complications of malaria are :

Tropical splenomegaly - This syndrome occurs in malaria endemic regions. WHO criteria for the diagnosis are :-

1. Major criteria : (a) Gross splenomegaly, (b) Immunity to malaria, (c) Serum IgM elevation > 2 SD i.e.1000 IU/ml. (d) Clinical & immunological response to antimalarial drugs
   
   
2. Minor criteria : (a) Hepatic sinusoidal lymphocytosis & Kupffer cell hyperplasia. (b) Cellular and humoral immune response to antigenic challenge. (c) Normal phytohaemagglutination,
   (d) Hypersplenism, (e) Lymphoid proliferation, (f) Occurrence in the family.

Quartan Malarial Nephropathy : This entity is seen with P.malariae infection following immune complex injury to glomeruli resulting in nephrotic syndrome. Prognosis is guarded.

Laboratory Diagnosis :
Clinical symptomatology of malaria is not specific and resembles many other diseases and hence there is a necessity of investigations. Malaria is diagnosed by microscopic examination of peripheral blood-thin and thick smears, after staining with JSB stain fields or Giemsa stain.

The thin film is more accurate for parasite counting, however at low parasitemia (< 5 per 100 RBCs), thick film should be counted. Presence of pigment in neutrophils and monocyte is important clue to the diagnosis and is even seen after anti-malarial treatment.

Special new techniques include:

1. Indirect flourescent antibody test,


2. Enzyme linked immuno-sorbant assay (ELISA),
   
3. DNA probe test which is specific for P.falciparum,
   
4. A solid phase radio immuno-assay,
   
5. Immunoblot test (Dip stick test) which does not need microscope and detects tropozoite derived histidine rich protein-2 (HRP-2),
   
6. QBC test (Qualitative Buffy Coat test) which is rapid method for diagnosing of malarial parasite in the blood and is highly sensitive and specific,
   
7. Malarial parasite staining -green (DNA) and orange (RNA) under the ultraviolet light.

Management of Malaria :
Aim in the treatment of malaria is to eliminate the erythrocytic form of malaria from circulating blood and in various organs and tissue and simultaneously to maintain good general condition of the patient. Hence treatment of malaria should include : 1. General measures, 2. Symptomatic and specific therapy, 3. Management of complications.

High index of suspicion is an important factor for success of treatment. Blood smear examination is necessary to confirm the diagnosis as well as to identify the species. However, treatment should not be delayed till the results of smears are available as negative smear does not rule out malaria, even cerebral malaria. If facilities are available, parasitic index should be done as it predicts the prognosis. Parasite count more than 2-10% predicts poor prognosis with fatality rate of more than 50% particularly in non-immune persons inspite of the treatment. Parasite count > 1% is usually not seen in non-falciparum type of malaria.