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Essays > Malaria (October 19, 1999 by Pat Heyman)
- May-may lay fragile and helpless as a baby under the weight of a dozen blankets. Her face was gray, her eyes ghastly. For four hours her teeth chattered. Then abruptly the chills changed to fever. Struan bathed her face with iced water but this brought no relief. May-may grew delirious. She thrashed in the bed, muttering and screaming an incoherent mixture of English and Chinese, consumed by the terrible fire. Struan held her and tried to comfort her, but she didn’t recognize him.
The fever disappeared as suddenly as it had come. Sweat gushed from May-may, drenching her clothes and the sheets. Her lips parted slightly and she uttered an ecstatic moan of relief. Her eyes opened and gradually began to focus. –Tai-Pan, James Clavell (1966)
The presentation of malaria varies widely with the patient and the species
of parasite, but the classic clinical picture is a series of fevers, or
paroxysms, with a regular period that malarial paroxysm takes place in
four stages:
- Chills
- The patient first feels cold (rigor) although his temperature is rising. His shivering may rattle the bed. "Teeth chatter, small hairs of the body stand erect in typical goose-flesh appearance, skin is dry, features pinched and blue, extremities somewhat cyanotic. The patient curls up in bed, covering himself with all available blankets, sweaters, and overcoats, but still feels cold (Russell 1963)." Tachycardia is present, but pulse is weak and thready. The chills may also be accompanied by headache, diarrhea, and vomiting.
- Hot Stage
- Throwing off all covers, the patient’s skin remains hot but dry. Instead of being blue, it may now take on an icteric tinge. Tachycardia remains, but pulse is now full and bounding. Headache, thirst, coated tongue, nausea, and vomiting may be present. Euphoria or delirium may be present. The temperature can rise higher than 106° F. This stage lasts from one to three hours.
- Sweating Stage:
- As suddenly as it begins, the fever ceases, and the patient begins to sweat profusely from every pore. The headache and tachycardia cease, and the patient may fall asleep, feeling relieved.
- Apyrexial Stage:
- Much like being in the eye of the hurricane, this stage is calm and the patient may want to resume normal activities, despite being weak and pale. This stage may last from 12 hours (P. falciparum) to 60 hours (P. malariae). Untreated, the paroxysms may occur as many as ten times, often increasing in severity. Death usually results from exhaustion and depletion of the body’s resources, both physical and mental. The untreated death rate is 25% (Russell 1963). Treatment usually confines the paroxysm to one or two cycles.
- Periodicity and non-classic presentation:
- Although this is the classic presentation, the disease may present itself as a periodic fever that does not respond to treatment accompanied by nausea, vomiting, and headache. The key is the periodic nature of the fever. Complicating diagnosis is the nature of the different species. P. vivax and P. ovale may form hypnozoites that that remain dormant in the liver for up to ten months. Chloroquine prophylaxis may prolong the incubation period even longer. The longest documented case in the literature had an incubation period of 20 years (Carlisle, 1999).
- Chronic malaria:
- Finally, malaria is considered a chronic disease. Once contracted, one may have the parasites for life, although treatment can reduce plasmodium blood levels to undetectable levels. If there is no relapse within the first two years, chances are good (>95%) that there will be no relapse. (Russell, 1963) However, relapses may occur regularly with stress, similar to herpes flare ups (Garrett, 1994).
Etiology
Pathogenesis
Morphology
Clinical Manifestations