Ver el código de «Malaria»

==Background==
[[File:Paludisme.png|thumb|right|upright=1.3|Distribution of malaria in the world (2010; see CDC website for current distribution):<ref> "Malaria". US Centers for Disease Control and Prevention. April 15, 2010. Archived from the original on April 16, 2012. Retrieved 2012-05-02.</ref>
 <span style="color:#7e0000; font-size:120%;">♦</span>&nbsp;Elevated occurrence of chloroquine- or multi-resistant malaria
<br> <span style="color:#f00; font-size:120%;">♦</span>&nbsp;Occurrence of chloroquine-resistant malaria
<br> <span style="color:#e08040; font-size:120%;">♦</span>&nbsp;No ''Plasmodium falciparum'' or chloroquine-resistance
<br> <span style="color:silver; font-size:120%;">♦</span>&nbsp;No malaria
]]
[[File:Anopheles stephensi.jpeg|thumb|Malaria vector: ''Anopheles stephensi'' mosquito.]]
[[File:Life Cycle of the Malaria Parasite.jpg|thumb|The life cycle of malaria parasites.]]

*Caused by parasitic protozoa species of the genus Plasmodium (''P ovale, P vivax, P malariae, P knowlesi'', and ''P falciparum'') carried by the Anopheles mosquito
**''P falciparum'' most severe
**Sickle Cell Trait (HbAS) is protective against severe ''P falciparum'' malaria
*Failure to consider for febrile illness following travel, even if seemingly temporally remote, can result in significant morbidity or mortality, especially in children and pregnant or immunocompromised patients
*Chemoprophylaxsis does not guarantee protection
*'''CDC Malaria Hotline''': 770-488-7788
*Malaria is a US nationally notifiable disease and all cases should be reported
*Malaria vaccine with ~30% efficacy will be piloted in African countries in 2018, study to assess pediatric mortality<ref>WHO. Ghana, Kenya and Malawi to take part in WHO malaria vaccine pilot programme. 24 April 2017. http://www.afro.who.int/en/media-centre/pressreleases/item/9533-ghana-kenya-and-malawi-to-take-part-in-who-malaria-vaccine-pilot-programme.html</ref>

===Traveler Precautions===
The CDC recommends travelers to malaria-endemic regions take the following precautions:<ref>WHO Malaria Policy Advisory Committee and Secretariat. Malaria Policy Advisory Committee to the WHO: conlusionsions and recommendations of September 2013 meeting. Malar J. 2013;12(1):456</ref>
*Use of insecticide-treated bed nets
*Use of DEET-containing insect repellents
*Wear long-sleeve shirts and pants
*Chemoprophylaxis
{| class="wikitable"
| align="center" style="background:#f0f0f0;"|'''Drug'''
| align="center" style="background:#f0f0f0;"|'''Regimen'''
| align="center" style="background:#f0f0f0;"|'''Dosage'''
| align="center" style="background:#f0f0f0;"|'''Side Effects'''
| align="center" style="background:#f0f0f0;"|'''Recommended Geography'''
<small>
|-
| [[Chloroquine]] || Begin weekly dosing 1-2 weeks before exposure and continue until 4 weeks after returning || 500mg weekly || Headache, itching, bitter taste. Rare serious dermatologic and ocular effects || First line in Central America, Mexico, Argentina, Paraguay, Hispaniola, Eastern Europe, Northern Africa, China, and parts of the Middle East
|-
| [[Atovaquone-proguanil]] (Malarone) ||Begin daily dosing 1-2 days before exposure and continue until 7 days after returning ||One pill (250mg/150mg) daily || Headache, nausea, abdominal pain, LFT increase. Avoid with renal dysfunction. || Second line agent; First line in areas of chloroquine resistance: Most of South America, sub-Saharan Africa, most of Asia, Oceania, and parts of Saudia Arabia, Yemen, Iran, and Oman
|-
| [[Mefloquine]] ||Begin weekly dosing 1-2 weeks before exposure and continue until 4 weeks after returning ||250mg weekly || Headache, Nausea, Diarrhea, Dizziness, Sleep Disturbance. Avoid with psychiatric disorders or arrhythmias || Second line agent; First line in areas of chloroquine resistance: Most of South America, sub-Saharan Africa, most of Asia (except Thailand, Myanmar, and Cambodia), Oceania, and parts of Saudia Arabia, Yemen, Iran, and Oman
|-
| [[Doxycycline]] || Begin daily dosing 1-2 days before exposure and continue until 4 weeks after returning ||100mg daily || Photosensitivity, Nausea || Second line agent; First line in areas of chloroquine resistance: Most of South America, sub-Saharan Africa, most of Asia, Oceania, and parts of Saudia Arabia, Yemen, Iran, and Oman
|-
| [[Hydroxychloroquine]] ||Begin weekly dosing 1-2 weeks before exposure and continue until 4 weeks after returning ||200mg weekly|| Headache, itching, bitter taste. Rare serious dermatologic and ocular effects || Second line agent
|-
| [[Primaquine]] ||Begin daily dosing 1-2 days before exposure and continue until 2 days after returning||30mg daily || Nausea, Diarrhea. Avoid with G-6-PD. || Second line agent</small>
|}

==Clinical Features==
[[File:38060783.png|thumb|Different fever patterns observed in Plasmodium infections.]]
[[File:Wmd 2020 flex.jpg|thumb|Child with malaria.]]
*[[Fever]] + exposure to [http://wwwnc.cdc.gov/travel/destinations/list.htm endemic country]
**Cyclic fever only after chronic infection
*Headache, cough, GI symptoms

===Classification===
'''Severe'''
*Any one of the following:
**[[Altered mental status]]/coma
**Severe normocytic anemia [hemoglobin < 7]
**Renal failure
**[[ARDS]]
**[[Hypotension]]
**[[DIC]]
**Spontaneous bleeding
**Acidosis
**Hemoglobinuria
**[[Jaundice]]
**Hepatomegaly
**Splenomegaly
**Repeated generalized [[seizures]]
**Parasitemia >5%

'''Uncomplicated'''
*None of the above

==Differential Diagnosis==
{{Fever in Traveler DDX}}

==Evaluation==
[[File:Plasmodium.jpg|thumb|Ring-forms and gametocytes of ''Plasmodium falciparum'' in human blood]]
*First smear positive in >90% of cases (thick and thin Giemsa stain)
**If initial negative, must be repeated BID x 2-3 days for proper exclusion of malaria
**Determines degree of parasitemia and type (e.g. ''P. falciparum'')
*Additional lab findings
**Normocytic [[anemia]]
**[[Thrombocytopenia]]
**↑ ESR
**↑ LDH
**LFT abnormalities (elevated indirect bilirubin)
**↑ Cr
**[[Hyponatremia]]
**[[Hypoglycemia]]
**[[Low Haptoglobin]]
**False positive VDRL

==Management==
*Mixed infections involving more than one species of Plasmodium may occur in areas of high endemicity (have a low threshold for including treatment for ''P falciparum'')<ref>World Health Organization. Guidelines for the treatment of malaria, 3rd ed, WHO, Geneva 2015. http://www.who.int/malaria/publications/atoz/9789241549127/en/</ref>
*[[Hyponatremia]] in the setting of hypovolemia does not require treatment beyond rehydration
*Treat [[hypoglycemia]]
*Check [[HIV]] status (coinfection can lead to worse clinical outcomes)
*[[Exchange transfusion]] for patients with:
**''P falciparum'' malaria with a parasitemia greater than 10% 
**Life-threatening complications (ie, coma, respiratory failure, coagulopathy, fulminant kidney failure)

{{Malaria antibiotics}}

===Cerebral Malaria===
*Insufficient evidence for or against giving antiepileptics
*For severe cerebral edema, mannitol and steroids have not shown a demonstrable benefit

==Disposition==
===Admit for===
*Patients with suspected or confirmed ''P falciparum'' or ''P knowlesi'' infection
*Young children
*Pregnant women
*Immunocompromised patients

===Admit to ICU for===
*Severe complications (e.g.coagulopathy or end-organ failure)
*Cerebral malaria (e.g. [[altered mental status]], repeated [[seizures]], coma)
*Parasitemia
**>2% in non-immune (i.e. travelers)
**>5% in semi-immune (i.e. locals)

==See Also==
*[[Travel Medicine]]
*[[Parasitic Diseases]]

==External Links==
*[https://www.iamat.org/risks/malaria?gclid=CIDPmoaO7csCFZSGfgod24UAfQ IAMAT world map and country details ]
*https://www.cdc.gov/parasites/malaria/index.html

==References==
<references/>

[[Category:ID]]
[[Category:Tropical Medicine]]