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==Overview==
==Overview==
Malaria parasites are transmitted by female ''[[Anopheles]]'' [[mosquito]]es. The parasites multiply within [[red blood cell]]s, causing symptoms that include symptoms of [[anemia]] (light headedness, [[shortness of breath]], [[tachycardia]] etc.), as well as other general symptoms such as [[fever]], [[chills]], [[nausea]], [[influenza|flu-like illness]], and in severe cases, [[coma]] and death.
The hallmark [[symptom]] of [[malaria]] is [[fever]], which commonly occurs in paroxysms, separated by fever-free time intervals. The classical but rarely observed malaria attack lasts 6-10 hours, and it consists of a cold stage, hot stage, and sweating stage.  Other common [[symptoms]] of [[malaria]] include [[chills]], [[headache]], [[nausea]], [[vomiting]], [[weakness]], [[night sweats]], [[flu]]-like symptoms, and [[myalgia]].  In the presence of a paroxysmal fever, travel history to a country where malaria is endemic is an important alert for the diagnosis.<ref name=Mandell>{{cite book | last = Mandell | first = Gerald | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | year = 2010 | isbn = 0443068399 }}</ref> Most importantly, malaria symptoms must be distinguished as to whether they reflect an uncomplicated or a severe course of infection. While uncomplicated infection is a benign process, severe malaria causes organ damage and is considered a medical emergency.


==History==
==History==
Obtaining a detailed history of the [[symptoms]] and travel history of the patient is an important step for the diagnosis of malaria. A travel history to a country where malaria is endemic, when in the presence of flu-like symptoms is an important alert for the diagnosis.<ref>{{cite book | last = Mandell | first = Gerald | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | year = 2010 | isbn = 0443068399 }}</ref>
In the presence of a paroxysmal fever, travel history to a country where malaria is endemic is an important alert for the diagnosis.<ref name=Mandell>{{cite book | last = Mandell | first = Gerald | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | year = 2010 | isbn = 0443068399 }}</ref> Following the infective bite by the Anopheles mosquito, a period of time ranging from 7 to 30 days goes by before the first symptoms appear.


After the mosquito bite, the typical incubation period of malaria may range from 8 to 25 days, in a primary attack. This period may be longer, depending on the status of the immune system of the host, the species and strain of the parasite, the dose of sporozoites, as well as the possible presence of prophylactic drugs. However, in the case of latent hypnozoites, relapses may occur within months to years after the mosquito bite.<ref>{{cite book | last = Mandell | first = Gerald | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | year = 2010 | isbn = 0443068399 }}</ref>
[[Fever]] in [[malaria]] is classically described as occurring in paroxysms of a few hours. These may be described as:
* ''Cold stage'': where the patient experiences [[rigors]] and [[chills]]
* ''Hot stage'': characterized by [[fever]], [[headaches]], and children may experience [[seizures]]
* ''Sweating stage'': characterized by [[sweats]], return to normal temperature with a feeling of [[fatigue]]


Commonly, the diagnosis of malaria should be considered in every patient who presents with an onset of fever and other related symptoms, who has traveled to a malaria-endemic region during the previous 3 months. Sometimes a wider time-frame may be considered.<ref>{{cite book | last = Mandell | first = Gerald | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Churchill Livingstone/Elsevier | location = Philadelphia, PA | year = 2010 | isbn = 0443068399 }}</ref>
The time-interval between [[fever]] paroxysms changes according to the type of [[plasmodium]] causing the disease:
* "Tertian" fever: paroxysms occur every second day, caused by "tertian" parasites:
** [[P. falciparum]]
** [[P. vivax]]
** [[P. ovale]]
* "Quartan" fever: paroxysms occur every third day, caused by the "quartan" parasite:
** [[P. malariae]]


===Fever Pattern===
==Symptoms==
Fever in malaria is classically described as following the stages described bellow:
===Common Symptoms===
* ''Cold stage'' - where the patient experiences [[rigors]] and [[chills]]
* ''Hot stage'' - characterized by [[fever]], [[headaches]], and children may experience [[seizures]]
* ''Sweating stage'' - characterized by [[sweats]], return to normal temperature with a feeling of [[fatigue]]
<!--
Paroxysms last several hours, can occur with a regular periodicity coinciding with the synchronous rupture of blood schizonts, may alternate with relatively asymptomatic periods, and are associated with high levels of tumor necrosis factor-α (TNF-α).34 Paroxysms can occur in tertian 48-hour or quartan 72-hour cycles, or in other more complicated pat- terns.35 TNF-α may originate from monocytes stimulated by glycosyl phosphatidylinositol moieties or other substances released on schizont rupture.
-->
 
==Common Symptoms==
* [[Fever]]
* [[Fever]]
* [[Chills]]
* [[Chills]]
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* [[Weakness]]
* [[Weakness]]
* [[Night sweats]]
* [[Night sweats]]
* [[Nausea]]
* [[Vomiting]]
* [[Insomnia]]
* [[Insomnia]]
* [[Joint pain]]
* [[Joint pain]]
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* [[Abnormal posturing]] (children)
* [[Abnormal posturing]] (children)


==Less Common Symptoms==
===Less Common Symptoms===
 
* [[Nausea]]
* [[Vomiting]]
* [[Diarrhea]]
* [[Diarrhea]]
* [[Abdominal cramps]]
* [[Abdominal cramps]]
* Feeling of tingling in the skin
* Feeling of [[tingling]] in the skin
* Bloody urine
* [[Bloody urine]]
* [[Convulsions]]
* [[Convulsions]]


==Distinguishing Uncomplicated vs. Severe Symptoms==
Malaria may either present as an uncomplicated infection or as a severe infection. While the former follows a benign course, the latter is characterized by target organ damage. More importantly, recognition of the severity of malarial symptoms is important because severity directly alters the management plan and the treatment options for patients with malaria.


<!--
The following table compares symptoms of uncomplicated malaria and severe malaria.
In other infections, fever may be cyclical, recurring every 48 or 72 hours, depending on the species and synchrony of the replicating parasites. Parasite subpopulations on different cycles in the blood- stream may produce complicated fever patterns. Patients with cyclical fevers may be relatively asymptomatic during afebrile periods.
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
|+'''''Comparison of Malaria Infections According to Severity''''' <ref>({{cite web |url=http://www.cdc.gov/malaria/about/disease.html |title= Malaria |date= Nov. Feb 8 2010 |website= Center for Disease Control and Prevention|publisher= Center for Disease Control and Prevention (CDC)|accessdate=Jul 24 2014}})</ref>
! style="background: #4479BA; width: 120px;" | {{fontcolor|#FFF|Severity}}
! style="background: #4479BA; width: 550px;" | {{fontcolor|#FFF|Clinical Significance}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Uncomplicated'''
| style="padding: 5px 5px; background: #F5F5F5;" |


Cyclical paroxysms of chills and rigors, fever, and drenching sweats are characteristic although not necessarily specific for malaria.
Attack lasts 6-10 hours consisting of 3 stages
*Cold stage: Shivering
*Hot stage: Fever, vomiting, and seizure
*Sweating stage: Sweating and fatigue


A travel history that reveals risk of exposure months to years before in an endemic region is an alert for malaria and should always be sought in presentations of fever.


Findings on physical examination may include pallor and hepatosplenomegaly. Rarely, acute Plasmodium infections present with splenic rupture requiring surgery or conservative management.
Non-specific symptoms
*Chills
*Sweating
*Headache
*Nausea and vomiting
*Body aches
*General malaise


Findings such as jaundice, diminished consciousness, or convulsions indicate severe malaria (see later). Rash, lymphadenopathy, and signs of pulmonary consolidation are distinctly uncommon.


Physical findings
*Fever
*Tachypnea
*Perspiration
*Weakness
*Hepatosplenomegaly
*Jaundice


* The classical symptom of malaria is cyclical occurrence of sudden coldness followed by rigor and then fever and sweating lasting four to six hours, occurring every two days in ''P. vivax'' and ''P. ovale'' infections, while every three for ''P. malariae''.<ref name=RBMarmenia>[http://www.malaria.am/eng/pathogenesis.php Malaria life cycle & pathogenesis]. Malaria in Armenia. Accessed October 31, 2006.</ref>
|-
 
| style="padding: 5px 5px; background: #DCDCDC;" |'''Severe'''
* ''P. falciparum'' can have recurrent fever every 36-48 hours or a less pronounced and almost continuous fever.
| style="padding: 5px 5px; background: #F5F5F5;" |
 
Malaria complicated by organ damage. It is considered a medical emergency that requires prompt hospitalization.
-->
*Cerebral malaria: Altered mental status, seizures, coma, neurologic deficit
*Hemolytic anemia: Hemoglobinuria, jaundice, splenomegaly
*Coagulopathy
*Acute respiratory distress syndrome (ARDS): Dyspnea, cough, hypoxia
*Cardiovascular collapse
*Acute kidney injury
*Metabolic acidosis
*Hypoglycemia
|-
|}


==References==
==References==
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[[Category:Tropical disease]]
[[Category:Tropical disease]]
[[Category:Deaths from malaria]]
[[Category:Deaths from malaria]]
[[Category:Infectious disease]]
 
[[Category:Disease]]
[[Category:Disease]]
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Latest revision as of 18:00, 18 September 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

Overview

The hallmark symptom of malaria is fever, which commonly occurs in paroxysms, separated by fever-free time intervals. The classical but rarely observed malaria attack lasts 6-10 hours, and it consists of a cold stage, hot stage, and sweating stage. Other common symptoms of malaria include chills, headache, nausea, vomiting, weakness, night sweats, flu-like symptoms, and myalgia. In the presence of a paroxysmal fever, travel history to a country where malaria is endemic is an important alert for the diagnosis.[1] Most importantly, malaria symptoms must be distinguished as to whether they reflect an uncomplicated or a severe course of infection. While uncomplicated infection is a benign process, severe malaria causes organ damage and is considered a medical emergency.

History

In the presence of a paroxysmal fever, travel history to a country where malaria is endemic is an important alert for the diagnosis.[1] Following the infective bite by the Anopheles mosquito, a period of time ranging from 7 to 30 days goes by before the first symptoms appear.

Fever in malaria is classically described as occurring in paroxysms of a few hours. These may be described as:

  • Cold stage: where the patient experiences rigors and chills
  • Hot stage: characterized by fever, headaches, and children may experience seizures
  • Sweating stage: characterized by sweats, return to normal temperature with a feeling of fatigue

The time-interval between fever paroxysms changes according to the type of plasmodium causing the disease:

  • "Tertian" fever: paroxysms occur every second day, caused by "tertian" parasites:
  • "Quartan" fever: paroxysms occur every third day, caused by the "quartan" parasite:

Symptoms

Common Symptoms

Less Common Symptoms

Distinguishing Uncomplicated vs. Severe Symptoms

Malaria may either present as an uncomplicated infection or as a severe infection. While the former follows a benign course, the latter is characterized by target organ damage. More importantly, recognition of the severity of malarial symptoms is important because severity directly alters the management plan and the treatment options for patients with malaria.

The following table compares symptoms of uncomplicated malaria and severe malaria.

Comparison of Malaria Infections According to Severity [2]
Severity Clinical Significance
Uncomplicated

Attack lasts 6-10 hours consisting of 3 stages

  • Cold stage: Shivering
  • Hot stage: Fever, vomiting, and seizure
  • Sweating stage: Sweating and fatigue


Non-specific symptoms

  • Chills
  • Sweating
  • Headache
  • Nausea and vomiting
  • Body aches
  • General malaise


Physical findings

  • Fever
  • Tachypnea
  • Perspiration
  • Weakness
  • Hepatosplenomegaly
  • Jaundice
Severe

Malaria complicated by organ damage. It is considered a medical emergency that requires prompt hospitalization.

  • Cerebral malaria: Altered mental status, seizures, coma, neurologic deficit
  • Hemolytic anemia: Hemoglobinuria, jaundice, splenomegaly
  • Coagulopathy
  • Acute respiratory distress syndrome (ARDS): Dyspnea, cough, hypoxia
  • Cardiovascular collapse
  • Acute kidney injury
  • Metabolic acidosis
  • Hypoglycemia

References

  1. 1.0 1.1 Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.
  2. ("Malaria". Center for Disease Control and Prevention. Center for Disease Control and Prevention (CDC). Nov. Feb 8 2010. Retrieved Jul 24 2014. Check date values in: |accessdate=, |date= (help))


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