Initial assessment of the patient with falciparum malaria

Critically ill patients with malaria will almost invariably have falciparum malaria. If other forms of malaria are reported, the clinician should consider mixed infections, laboratory error in speciation, or other diagnoses with non-falciparum malaria as an incidental finding.

It is easy to underestimate severity in falciparum malaria. The parasite goes through a repeating cycle of development and reproduction, and it is only at certain points of the cycle that significant pathological damage occurs. This makes assessment much more difficult than for other infections. A patient can appear clinically well and then deteriorate rapidly, despite adequate treatment, as parasites mature. A low parasite count does not mean that the infection is trivial, and many of the complications of malaria can occur after all parasites have been cleared from the peripheral blood.

Any or all of the following signs or test results indicate a complicated case of malaria which will need intensive monitoring and treatment, and in which rapid deterioration is likely (World H.ea.!th OigMn.i.z.aiio.n 1.9.9.0):

1. reduction in conscious level;

2. neurological signs or fits;

3. renal impairment (creatinine above 250 pmol/l) or oliguria;

4. shock or hypotension;

5. parasite count above 5 per cent on blood film;

6. anemia (hematocrit below 15 per cent);

7. signs of bleeding or disseminated intravascular coagulation (DIC);

8. jaundice;

9. pulmonary edema, hypoxia, or acidosis; 10. hypoglycemia (glucose below 2.2 mmol/l).

Where neurological signs or coma are present, hypoglycemia should be immediately excluded since it is caused by both severe malaria and antimalarial drugs. Pregnant women are at particular risk. In the absence of these, the following factors indicate a potentially complicated case:

1. pregnancy;

3. parasite count above 1 per cent;

4. mature parasites (schizonts or late trophozoites) on the blood film.

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