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KEY POINTS

KEY POINTS

  • Malaria is a serious global health care problem, with approximately half the world’s population living in areas at risk of malaria transmission.

  • The most vulnerable individuals are those with little or no immunity against the disease and include young children, pregnant women, travellers, and migrants from areas with low or no malaria transmission.

  • Severe malaria is a medical emergency characterized by multiorgan disease.

  • A diagnosis of severe malaria should be considered in all patients with severe febrile illness, illness acquired in a malaria-endemic area, or in those with a history of travel. A travel history should always be obtained from patients presenting with febrile illness.

  • Severe malaria and malaria mortality are mainly caused by Plasmodium falciparum, but both Plasmodium vivax and Plasmodium knowlesi can also cause severe disease.

  • Microcirculatory impairment caused by sequestration of parasite-infected erythrocytes, red cell rigidity, and red cell clumping differentiates severe malaria pathophysiologically from bacterial sepsis.

  • Early diagnosis (confirmed by microscopy or rapid diagnostic testing) and treatment are essential to prevent disease progression and limit mortality in severe malaria.

  • Parenteral artesunate is the drug of choice to treat severe malaria in all patient groups, including children, pregnant women, and travellers.

  • Presenting manifestations with the strongest prognostic significance are coma (cerebral malaria), metabolic (lactic) acidosis, and renal dysfunction.

  • The most common pitfalls to avoid in the management of severe malaria include delay of initiation of antimalarial treatment, failure to recognize hypoglycemia, and overly zealous fluid administration in patients without hypotension (cautious and judicious fluid administration is advised in these patients to prevent potentially lethal pulmonary edema).

INTRODUCTION AND HISTORICAL PERSPECTIVE

Malaria is a life-threatening multiorgan disease and serious global health care problem.1 It has plagued humans throughout history and has often been alluded to as the “King of Diseases.”2,3 Malarial DNA going back 4000 years has been identified in Egyptian mummy tissue as well as in amber dating back more than 100 million years.

EPIDEMIOLOGY AND GLOBAL DISTRIBUTION

Malaria is a leading cause of death and disease in malaria-endemic regions such as sub-Saharan Africa, South-East Asia, the Eastern Mediterranean, Western Pacific, and South and Central America1,4,5 (see Table 81-1). It is also an increasingly important cause of significant imported infection in nonendemic areas among returning travellers who have visited endemic regions.1,6–9 The disease is caused by parasites belonging to the genus Plasmodium that are transmitted to humans via the bite of infected female Anopheles mosquito vectors.1,2,5 If the disease is not treated timely, progression to severe disease with organ dysfunction and death may occur, depending on the infecting Plasmodium species and immune status of the patient.1,2,4,5,10,11 Six Plasmodium species can cause malaria in humans: Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae, the sympatric species Plasmodium ovale curlisi and Plasmodium ovale wallikeri, as well as the zoonotic ...

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