Clinical picture, acute severe malaria

Acute severe falciparum malaria is a medical emergency. This encompasses:

• Coma (the patient cannot be woken)

• Repeated generalised convulsions

• Hypoglycaemia: reduced consciousness, aggressive behaviour

• Severe anaemia: weakness, polypnoea, pale mucosae

• Tendency to spontaneous bleeding (pronounced thrombocytopaenia)

• Circulatory collapse (shock); cf. algid malaria

• Pulmonary oedema (dyspnoea and bilateral crepitations) ± ARDS

• Haemoglobinuria (dark urine)

• Kidney failure: the urinary flow should be monitored and kept above 400 ml/24h.

• Acidosis (chiefly due to lactic acid): rapid deep respiration. If too many salicylates are given, this may exacerbate the acidosis (not unusual in febrile patients).

Other important signs are: confusion without coma, extreme generalised weakness, jaundice, very high fever (hyperpyrexia). The priorities are cerebral involvement, severe anaemia, hypoglycaemia and kidney failure, and the presence of hyperparasitaemia. The degree of parasitaemia correlates with the severity of the symptoms: the higher the parasitaemia, the greater the risk of severe symptoms. It should be borne in mind that the parasitaemia (the percentage of parasitised cells that are found in a smear preparation) changes by the hour. This is because the red blood cells with mature P. falciparum parasites (schizonts) attach themselves to the small capillaries of deep organs, and are not found in a thin blood smear. A parasitaemia of 0.5% is already severe, 2% is pronounced, and patients with a parasitaemia of more than 10% have a relatively poor prognosis. Over 25% is often fatal. Another consideration is that a parasitaemia of 3% in someone who still has a normal red blood cell count, is different from a parasitaemia of 3% in an anaemic patient.

Category: Medicine Notes