Complications
Usually due to dehydration and hypovolaemia, but can also be due to acute tubular necrosis in severe disease.
Often reversible if treated appropriately with careful attention to fluid status, but may require renal support.
Common with severe disease and may be worsened by quinine therapy. Pregnant women are most at risk.
Blood glucose levels should be checked every 4 hours.
May be treated or prevented with 5% to 10% dextrose.
Occurs secondary to tissue hypoxia resulting from hypovolaemia, hypotension, and anaemia. Deep breathing is 91% sensitive and 83% specific for underlying metabolic acidosis, but arterial blood gas will confirm the diagnosis.[169]
Careful fluid balance is imperative, but caution should be taken not to precipitate pulmonary oedema, which may occur due to increased pulmonary capillary permeability.
Most common in young children due to direct red cell lysis, autoimmune haemolysis, and disturbed marrow function. Easily detected by laboratory testing and treated with cautious transfusion.
Bleeding gums, epistaxis, and petechiae in severe disease. Haematemesis and/or melaena are less common.
Intravascular haemolysis resulting in haemoglobinuria (known as blackwater fever) may occur during the treatment of malaria. It is more commonly seen in patients with severe malaria who are treated with quinine or mefloquine, although there have been cases reported in patients with uncomplicated disease treated with other antimalarials.[170]
Concomitant septicaemia should be considered in the presence of persistent fever or neurological deterioration despite adequate antimalarial therapy, or if focal signs of infection develop.
Occurs in severe disease and may be multifactorial (metabolic disturbance, hypoglycaemia, anaemia). May be gradual or sudden-onset. Presents with disturbance of cerebral function such as confusion, reduced level of consciousness, or seizures. Consider performing a lumbar puncture to exclude the possibility of concomitant bacterial meningitis.
How to perform a diagnostic lumbar puncture in adults. Includes a discussion of patient positioning, choice of needle, and measurement of opening and closing pressure.
Seizures should be terminated promptly and may require loading with anticonvulsants if recurrent. Reversible factors should be corrected (e.g., electrolyte disturbance, glucose disturbance, hypoperfusion, hypoxia). Patients will need intensive care.
Post-malaria neurologic syndrome is a rare, self-limiting neurologic complication that can occur after recovery, usually after severe falciparum malaria. It can develop up to 2 months after clearance of parasitaemia, and usually occurs after a symptom-free period. It is thought to be an immune-mediated reaction of the central nervous system rather than a direct parasitic effect. Clinical features are variable, but include a milder form characterised by isolated cerebellar ataxia or postural tremor, a diffuse encephalopathic form with confusion or seizures, and severe encephalopathy. Some experts classify this syndrome as a form of acute disseminated encephalomyelitis. Severe cases may require corticosteroid therapy.[171][172]
Pulmonary oedema in severe disease has a poor prognosis and a high mortality rate and occurs with features of respiratory distress syndrome (ARDS). The prevalence of ARDS in patients with malaria is 2.8% (children) and 2.2% (adults), with a nearly 50% mortality rate.[173]
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