Clinical spectrum and management of severe/complicated
Contrary to the widespread belief that severe malaria is mainly caused by Plasmodium falciparum, malaria caused by Plasmodium vivax infection may also lead to severe clinical manifestations including a plethora of renal, pulmonary, hematologic, neurologic, and multiorgan dysfunction. Anemia and thrombocytopenia are considered as two major important markers of severity during the clinical course of severe P. vivax malaria. In highly endemic areas of P. vivax transmission, early diagnosis is crucial in preventing uncomplicated episodes progressing into severe and complicated clinical forms. In fact, given the wide geographic distribution of P. vivax, there is a large burden of disease, often not adequately acknowledged, and resulting from the combined effect of the large numbers of uncomplicated clinical episodes and the increasingly recognized severe and complicated clinical presentations.
- Plasmodium vivax
- clinical manifestations
Globally, malaria remains one of the most important infectious diseases affecting humankind in terms of morbidity and mortality [1, 2].
The clinical spectrum of disease associated with
2. Parasitology and epidemiology
Infection due to
3. Pathogenesis and disease transmission
The clinical spectrum of disease of
4. Clinical manifestations
When evaluating patients presenting with a clinical syndrome compatible with malaria, there are no specific signs or symptoms to assist clinicians in distinguishing infection due to Plasmodium vivax or plasmodium falciparum; or when there is coinfection by the two species. Fever in young children may produce seizures. Some individuals progress rapidly to respiratory failure caused by either pulmonary edema or even acute respiratory distress syndrome (ARDS). Among those with rapid clinical deterioration, we should always consider the concomitant risk of gram-negative bacteremias among individuals with either
Acute kidney injury may occur in both children and adults, and it may result for oliguric renal failure or even from acute tubular necrosis [24, 25]. Many patients present with multi-organ failure and hemodynamic instability requiring vasopressor support and often mechanical ventilation. Others may develop acute kidney injury from hypovolemic shock secondary to splenic rupture. All of these potential clinical scenarios should be considered among those with severe
5. Diagnosis of severe vivax malaria
Appropriate management of individuals with
6. Treatment of severe vivax malaria
A summary of core concepts in the management of severe malaria due to
|Clinical category||Core concepts|
|Respiratory failure||Protect airway|
Provide supplemental oxygen
Rule out other causes of concomitant respiratory failure (i.e., bacterial pneumonia, pulmonary embolism, or others)
|Acute pulmonary edema||Oxygen supplementation|
BIPAP or mechanical ventilation via endotracheal intubation if needed. Patient often requires PEEP given the possibility of ARDS
|Shock||Potentially caused by either hypovolemia due to bleeding or septic shock from gram-negative bacteremia|
Obtain blood cultures; administer broad spectrum antibiotics; correct hemodynamic disturbances
Rule out splenic rupture with abdominal ultrasound or computed tomography
|Acute renal failure||Exclude prerenal causes|
Hemodialysis or hemofiltration if indicated (i.e., worsening acute kidney injury, acute tubular necrosis, concomitant severe acidosis, and/or hyperkalemia)
Other antiseizure medications: Dilantin
|Acidosis||Exclude or treat hypoglycemia, hypovolemia, and sepsis|
If severe, performing hemofiltration or hemodialysis is indicated
|Severe anemia||Blood transfusion|
|Antiparasitic treatment||First-line treatment|
Second-line treatment of complicated malaria
Quinine dihydrochloride combined with either clindamycin (300 mg) or doxycycline (100 mg) tablets
Presumptive anti-relapse therapy with primaquine is required to eradicate the liver stage of
The spread of drug-resistant
Malaria infection remains as a leading infectious diseases affecting humankind due to its associated large burden of disease. There is a growing recognition that
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