Case history
Case history #1
A 42-year-old Nigerian woman presents to her primary care physician with a 2-day history of fever, chills, and sweats with associated headache and myalgia. She is febrile (101.4°F [38.6°C]) and tachycardic, but examination is otherwise unremarkable. A presumptive diagnosis of influenza is made, and she is advised to return if she does not improve. Two days later she presents to the emergency room with similar symptoms and frequent vomiting. On examination she appears ill, with a temperature of 101.8°F (38.8°C), pulse rate 120 beats per minute, blood pressure 105/60 mmHg, and mild jaundice. Further history reveals that she recently visited family in Nigeria for 2 months, returning 1 week before presentation. She did not take malaria prophylaxis.
Case history #2
A 28-year-old man presents to his physician with a 5-day history of fever, chills, and rigors, not improving with acetaminophen, along with diarrhea. He had been traveling in Central America for 3 months, returning 8 weeks ago. He had been bitten by mosquitoes on multiple occasions, and although he initially took malaria prophylaxis, he discontinued it due to mild nausea. He does not know the specifics of his prophylactic therapy. On examination he has a temperature of 100.4°F (38°C), and is mildly tachycardic with a blood pressure of 126/82 mmHg. The remainder of the examination is normal.
Other presentations
The symptoms of malaria are nonspecific, and their severity depends in part on the infecting species and host immunity. Adults who live in endemic areas may develop only minimal symptoms, due to immunoglobulin G antibody and cell-mediated immunity, and to physiologic tolerance of parasitemia. However, individuals without preexisting immunity, pregnant women, children, older adults, and those with comorbidities (e.g., HIV infection) or malnutrition are more at risk of severe malaria with Plasmodium falciparum. Pregnant women are also at risk of miscarriage, anemia, and hyperparasitemia. Complications of severe malaria include cerebral involvement, which may present as reduced consciousness level, confusion, or seizures. Other complications include metabolic acidosis leading to respiratory distress, renal impairment, jaundice, severe anemia, hypoglycemia, disseminated intravascular coagulation, and shock. It is important to consider concurrent bacterial sepsis if there is shock or there are focal symptoms or signs. Lymphadenopathy (usually an important negative finding) has been reported in a case report.[5] While nonfalciparum infections are usually uncomplicated, there have been reports of severe disease, particularly with P vivax or P knowlesiinfection.[6]
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