Evaluation of Cases of Malaria

Malaria is a very simple disease to diagnose and treat; yet it claims more lives than any other infectious disease in the world. It is therefore very essential that every case of malaria be assessed thoroughly.

General: Functional status, prostration, breathlessness, level of consciousness, hydration, toxicity, puffiness of face and lids, etc.

Vital signs: Pulse rate, blood pressure (hypotension), temperature (hyperpyrexia), respiratory rate (tachypnoea, acidotic breathing).

Other signs: Pallor, Jaundice, Cyanosis, Edema, etc.

Abdomen: Liver, spleen, bowel sounds - Tender hepato/ splenomegaly is more common in acute malaria.

Respiratory system: Basal crackles, wheezes; sometimes, associated pneumonia and its bronchial breath sounds.

C.N.S.: Level of sensorium, convulsions, neck stiffness, ocular fundii, any focal deficits.

Hemoglobin: Anemia is common in malaria. Rapid reduction in level of hemoglobin is seen in falciparum malaria and less than 7 g/ dl should be a warning.

Total leukocyte count: It can vary from low to high, and neutrophilic leukocytosis is common in severe malaria with or without associated bacterial infection. Leukopenia is seen in severe malaria with septicemia, and chronic hypersplenism.

Platelet count: Thrombocytopenia is common in P. falciparum and P. vivax malaria, but it does not correlate with the severity of the infection.

Parasite count: This is a simple yet very important and useful method of assessing the severity of infection in falciparum malaria. It should be done routinely in all cases of falciparum malaria.

Thick film: The density of malarial parasites can be read against the leukocytes and an approximate parasite count can be calculated.

1. Count the number of asexual forms of the parasite ( rings, trophozoites and schizonts) against 100 leukocytes and multiply by 75, this gives an approximate total per micro liter (mm³).
2. The average leukocyte count per microscopic field is about ten. Therefore, multiply the average number of parasites per field by 750, this also gives an approximate total per micro liter.

Thin film: Count the number of parasites within 1000 red blood cells and divide this by 10. This gives the percentage of parasitemia.

A parasite count of 100000 or more per mm³ (or 5% and more) is considered as severe infection.

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Blood Glucose: Hypoglycemia is a common problem encountered in malaria and may remain undetected because the symptoms and signs of hypoglycemia viz. sweating, tachycardia etc., are even otherwise seen in malaria. It is very important to monitor the blood glucose levels once at least 6 hours in falciparum malaria, particularly if the patient is pregnant or is receiving quinine.

Moderate elevation in blood urea and creatinine are common. Significant increase is suggestive of renal impairment.

Hyperbilirubinemia is common in malaria, particularly due to hemolysis. Some patients with falciparum malaria may have very high levels of conjugated bilirubin due to associated hepatocyte dysfunction.

Serum albumin levels may be reduced, some times markedly.

Serum aminotransferases, 5' - nucleotidase and lactic dehydrogenase are elevated.

Prothrombin time and partial thromboplastin time are elevated in 20% of patients with cerebral malaria. Some may have features of disseminated intravascular coagulation.

Hyponatremia is common and needs careful management.

Lactic acidosis is seen in severely ill patients, especially in patients with hypoglycemia and renal dysfunction. It can be suspected if there is a wide anion gap.

Urine examination may show albuminuria, microscopic hematuria, hemoglobinuria and red cell casts. With massive intravascular hemolysis, urine may be black in colour.

SEE - Misjudgement of severity

1. Persistence of fever even after 48 hours of initial treatment.
2. Continuously worsening headache.
3. Persistent vomiting.
4. Any complications of P. falciparum malaria- altered sensorium, convulsions, anemia, jaundice, hyperpyrexia, bleeding and clotting disorders, breathlessness, high coloured urine etc.
5. Patients who are at higher risk for development of complications of P. falciparum malaria-extremes of age, pregnancy, immunocompromised etc.
6. Patients who appear sick and prostrated
7. Significant dehydration

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