Makindo Medical Notes

⚠️ Always consider falciparum malaria in anyone with a flu-like illness returning from an endemic area within the last 3 months. 👉 Send urgent thick and thin films, inform the lab, and involve Infectious Diseases early. ⏱ A patient can deteriorate and die before the post-take ward round – the diagnosis must be suspected at first contact.

📖 About

• Falciparum malaria is the most lethal form – death may occur within hours.
• Any red cell involvement >2% = severe disease.
• BNF Malaria Guidance

🦟 Vector & Parasite

• Spread by the female Anopheles mosquito.
• Caused by the protozoan parasite Plasmodium falciparum.
• Other routes: transfusion, needlestick, “airport malaria” (imported mosquitoes).

• Cytoadherence: Infected RBCs stick to endothelium → block venules.
• Mediated by PfEMP-1 on red cell surface.
• Leads to cerebral, renal, pulmonary, and multi-organ damage.
• Rosetting: Infected cells clump with normal RBCs, worsening occlusion.

🌍 Epidemiology

• ~1 million deaths per year globally.
• Endemic in Sub-Saharan Africa, SE Asia, and parts of South America.
• In the UK, malaria is an imported disease.

🔄 Life Cycle (Simplified)

• 🦟 Mosquito bite → sporozoites enter liver.
• 🩸 Liver stage → merozoites released into blood.
• RBC stage → multiplication and rupture of RBCs (rigors, fever, anaemia).
• Adherence to endothelium → organ damage (brain, kidney, lung, gut).

• Flu-like illness: fever, malaise, headache, rigors.
• Hepatosplenomegaly (mild).
• Severe: cerebral malaria → coma, seizures, hemiparesis, blindness.

⚠️ Complications

• Coma, seizures (reduced GCS).
• Acute renal failure (10% need dialysis).
• Metabolic acidosis, hypoglycaemia (from parasite + quinine).
• Severe anaemia, haemolysis, jaundice.
• “Blackwater fever” (haemoglobinuria).
• DIC, thrombocytopenia.
• ARDS / non-cardiogenic pulmonary oedema.

🧪 Investigations

• Bloods: FBC, U&E, LFTs, glucose, lactate, blood cultures.
• Films: 3–5 thick & thin blood films over 48 hrs. Thick = parasite detection, Thin = speciation + parasitaemia %.
• Parasitaemia >5% or pre-schizont forms → poor prognosis.
• Rapid antigen detection (useful in UK hospitals).
• Other: CXR (pneumonia), urinalysis, stool culture, COVID test if relevant.

🔎 Differentials (coinfection possible!)

• Dengue, Typhoid, Schistosomiasis, Tick typhus.
• TB, Dysentery, Influenza, Viral or bacterial pneumonia.
• HIV, bacterial sepsis, meningitis.

💊 Management (BNF-linked)

• 🟢 Uncomplicated falciparum malaria (oral):
  • Quinine 5–7 days + doxycycline (7 days) or clindamycin (7 days).
  • Atovaquone-proguanil (Malarone).
  • Artemether-lumefantrine (Riamet).
• 🔴 Complicated malaria:
  • Resuscitate: ABCDE, HDU/ICU, fluids + glucose monitoring.
  • IV Artesunate (preferred) 2.4 mg/kg at 0, 12, 24 hrs then daily.
  • Alternative: IV Quinine 20 mg/kg loading → 10 mg/kg 8-hourly. Switch to oral once stable. Complete 7-day course with doxycycline/clindamycin.
  • Correct hypoglycaemia, treat bacterial co-infection, manage seizures.
• 🤰 Pregnancy:
  • Extremely high risk (esp. 3rd trimester).
  • Quinine is safe; add clindamycin (not doxycycline).
  • Specialist input: Artesunate may be used in severe cases.

📞 UK Expert Advice

• PHE Malaria Reference Laboratory: 020 7637 0248
• NaTHNaC: 0845 602 6712
• HPS Travax (Scotland): www.travax.nhs.uk
• Regional Centres: Birmingham, Liverpool, London, Oxford