Injections for Malaria Treatment?

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QUESTION

I have a friend that just told me that she has Malaria. She said she has to go to the hospital every day for an injection for around the next 2 weeks. Is this a typical treatment. Why not just take pills? I`m just trying to wrap my head around this and understand the different treatments.

ANSWER

This is certainly not typical treatment for malaria. Uncomplicated malaria is usually treated with oral medication, and the type depends on the type of malaria you have. The most severe form of malaria, Plasmodium falciparum, is often resistant to chloroquine (still the first-line drug of choice for P. malariae, P. knowlesi and P. ovale infections, as well as for P. vivax in most parts of the world) and so first-line treatment is now usually an artemisinin-based combination therapy (ACT), such as Coartem.

As far as I am aware, it is only in cases of complicated, severe malaria that intravenous or intramuscular treatment is used (usually quinine), and in those cases, treatment would not be administered on an outpatient basis. It may be that your friend has a specific medical requirement for a non-oral form of medication, but it is definitely unusual!

How is Malaria Treated

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QUESTION

How is malaria treated?

ANSWER

This answer is copied from an earlier question about the various available cures for malaria.

Malaria can be cured with a number of different medications, depending on then type of malaria and how far the disease has been progressed.

For standard, non-complicated Plasmodium falciparum malaria, the World Health Organisation recommends use of artemisinin-based combination therapies (ACTs), such as Coartem. This is due to increasing levels of resistance to chloroquine in many parts of the world. Indeed, even though chloroquine is still used in many places as first-line treatment against P. vivax, P. malariae, P. ovale and P. knowlesi uncomplicated malaria, there is some evidence that resistance to this treatment is also emerging, for example in P. vivax in parts of south-east Asia.

In cases where malaria infection has progressed to a stage where oral administration of medication is not possible, or where cerebral symptoms are suspected, the usual treatment option is intravenous quinine.

In addition, P. vivax and P. ovale malaria parasites are able to produce forms (called hypnozoites) which can become dormant in liver hepatocyte cells after the blood stages of the infection have been cleared. These dormant forms can become reactivated weeks or even months or years after the initial infection, which is called a “relapse” of the infection. One drug, called primaquine, is able to kill these liver stages, and so patients with either of these types of malaria should also discuss the possibility of taking primaquine.

Apart from these first-line treatments, there are other medications which are used against malaria, both prophylactically as well as for treatment. These include orally-administered quinine, pyrimethamine, mefloquine, proguanil, atovaquone and sulfonamides.

 

Who introduced malaria in which century?

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QUESTION

Who introduced malaria in which century, how does it cause malaria and what is the virus’ name?

ANSWER

Malaria wasn’t introduced; it has been evolving alongside humans for thousands, if not millions of years. The first known mention of malaria by humans is in an ancient Chinese medical text, from 2700 BCE (before common era). Other ancient people, such as the Romans and the Greeks, knew the symptoms of malaria and described it in writing.

Malaria is actually not caused by a virus, but a single-celled animal called a protozoan. The genus name of the protozoans that cause malaria is Plasmodium, and there are five main species that infect humans: P. falciparum, P. vivax, P. ovale, P. malariae and P. knowlesi.

The malaria parasites cause the disease by entering into red blood cells and multiplying; when they have reproduced, they burst out of the red blood cell, destroying it. The patient’s blood is therefore rapidly full of malaria parasites, their waste products, plus bits of destroyed red blood cell; this produces an extreme immune reaction which causes many of the symptoms of malaria. In infection with P. falciparum, the most deadly and severe kind, infection with the parasite causes red blood cells to sequester in tiny red blood cells within major organs, causing reduced oxygen flow and complications. When this occurs in the brain, the result is cerebral malaria, which can result in convulsions and even a coma.

Signs of Malaria

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Hello my question is how do I see malaria signs if i haven’t gone to check yet?

 

The key is to recognise whether you have any potential symptoms of malaria, or if you have been bitten a lot by mosquitoes recently and live in an area where malaria is present. Malaria can have many different symptoms, but the initial signs are similar to a flu-like illness, with high fever, chills, headache and muscle soreness or aches. A characteristic sign of malaria is cyclical fever, with peaks of severity every two or three days. Additionally, some people will experience nausea, coughing, vomiting and/or diarrhea.

Because these symptoms are quite generic of a wide variety of illnesses, if you live in a malaria-endemic region, it is crucial to be tested when you develop such symptoms. If you have recently traveled to a malarial area and start to experience these signs of infection, similarly you should inform your doctor of your travel history, as otherwise they might not recognize your symptoms as potentially that of malaria.

If you live in a malarial area, you can always visit a clinic and see if they will do a test to screen you for malaria, even if you don’t have the above symptoms. People who live in malarial areas develop partial immunity to the disease, meaning that new infections do not always present themselves as acutely as when they were children, or in people who are being infected for the first time. As such, some people can have low levels of parasite in their blood and while they may feel tired or a bit under the weather, do not have specific symptoms. This is especially the case for the less severe and deadly forms of malaria, such as Plasmodium vivax, P. ovale and P. malariae, so if you live in an area where any of these three are present, it might be worth getting a malaria test even if you don’t have symptoms.

However, it is very important not to accept treatment unless you are confirmed as having a positive diagnosis for malaria; taking treatment without having the disease can lead to resistance to the medication, and you may also experience side effects, which, though usually mild, are still probably better to avoid!

Symptoms of Malaria

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QUESTION

What are the main symptoms of malaria?

ANSWER

Malaria can have many different symptoms, but the initial signs are similar to a flu-like illness, with high fever, chills, headache and muscle soreness or aches. A characteristic sign of malaria is cyclical fever, with peaks of severity every two or three days. Additionally, some people will experience nausea, coughing, vomiting and/or diarrhea.

Because these symptoms are quite generic of a wide variety of illnesses, if you live in a malaria-endemic region, it is crucial to be tested when you develop such symptoms, rather than assuming it’s just the flu and soldiering on! If you have recently traveled to a malarial area and start to experience these signs of infection, similarly you should inform your doctor of your travel history, as otherwise they might not recognize your symptoms as potentially that of malaria.

If treated rapidly and with the correct medication, malaria is almost always completely treatable; it is only if treatment is delayed that it becomes more serious, with long-lasting and potentially fatal consequences. Similarly, if you take sensible precautions while living or traveling in malarial areas, such as taking prophylaxis (and taking them as per the instructions, for the full required amount of time!), avoiding being bitten by mosquitoes and sleeping under an insecticide-treated bed-net, you vastly reduce your chances of getting infected in the first place.

It’s also worth noting that different species of Plasmodium, the parasite that causes malaria, cause slightly different manifestations of the disease, and also require different forms of treatment. Plasmodium falciparum has a unique way of affecting the red blood cells it infects, which eventually can result in loss of function of internal organs. ‘Cerebral malaria’ is a particularly deadly version of this, whereby the function of the brain is affected. The cycles of fever, mentioned above, are caused by synchronous rupturing of the red blood cells in the body by the malaria parasite; P. falciparum, P. vivax and P. ovale, complete this cycle every 48 hours, resulting in fever cycles of roughly two days (though P. falciparum can be unpredictable); P. malariae, on the other hand, has a cycle lasting 72 hours, so three day cycles of fever are expected. Finally, although many types of malaria can be successfully treated with the drug chloroquine, some strains, and notably of P. falciparum, have become resistant to this treatment. In these cases, artemesinin-based treatment is recommended, usually in combination with other therapies (artemesinin-combination therapy, or ACT). P. vivax, in addition, requires an additional drug, called primaquine, which is used to treat lingering liver stages of the parasite, to prevent recurrence of the infection.

Examination of Malaria Parasite

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QUESTION

How can you examine malaria parasites?

ANSWER

Malaria parasites are usually examined under a microscope using a peripheral blood smear method (also called a blood film). Thick blood smears, which use a large unsmeared drop of blood, are sensitive since a large number of red blood cells can be examined, though the parasites, if present, are difficult to distinguish morphologically.

For species-level identification of malaria parasites, a thin blood film is more commonly used, whereby a small volume of blood is smeared thinly across the slide and then stained, usually with Romanowsky stain, in order to see the detailed structures which differentiate the different species of malaria. It is crucial to make the blood films soon after the blood sample has been taken, and to store the blood in an appropriate anti-coagulate.

Characters to look out for include the presence of Maurer’s dots on the surface of red blood cells infected with Plasmodium falciparum. You may also see multi-infected red blood cells with this species, and it is rare to see mature trophozoites or schizonts with this parasite since when this stage is reached the red blood cells are usually sequestered deep within major organs and so are not readily present in the peripheral blood.

These parasites have crescent-shaped gametocytes. Plasmodium vivax, on the other hand, enlarges red blood cells that it infects and seems to show a preference for immature red blood cells. The presence of Schüffner’s dots is also characteristic – these looks like specks or granules on the cell surface of the infected red blood cell. P. ovale is very similar to P. vivax, in that it also enlarges the red blood cells and can have Schüffner’s dots, but fewer merozoites tend to be present per cell and infected red blood cells tend to look elongated. P. malariae does not alter the size or shape of the red blood cell it infects and tends to form rosette-like patterns of 8-10 merozoites. Later on in maturation, its trophozoites may form characteristic band-like patterns across the cell.

Pathophysiology of Malaria

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QUESTION

What is the pathophysiology of malaria?

ANSWER

Malaria causes disease through a number of pathways, which depend to a certain extent on the species. Malaria is caused by a single-celled parasite of the genus Plasmodium; there are five species which infect humans, being Plasmodium falciparum, P. vivax, P. ovale, P. malariae and P. knowlesi.

All these species are introduced into the human blood stream through the bite of an infected mosquito; the life stage of malaria at this point is called a “sporozoite”, and they pass first to the liver, where they undergo an initial stage of replication (called “exo-erythrocytic replication”), before passing back into the blood and invading red blood cells (called “erythrocytes”, hence this is the “erythrocytic” part of the cycle). The malaria parasites that invade red blood cells are known as merozoites, and within the cell they replicate again, bursting out once they have completed a set number of divisions. It is this periodic rupturing of the red blood cells that causes most of the symptoms associated with malaria, as the host’s immune system responds to the waste products produced by the malaria parasites and the debris from the destroyed red blood cells. Different species of malaria rupture the red blood cells at different intervals, which leads to the diagnostic cycles of fever which characterise malaria; P. vivax, for example, tends to produce cycles of fever every two days, whereas P. malaria produces fever every three.

In addition, Plasmodium falciparum produces unique pathological effects, due to its manipulation of the host’s physiology. When it infects red blood cells, it makes them stick to the walls of tiny blood vessels deep within major organs, such as the kidneys, lungs, heart and brain. This is called “sequestration”, and results in reduced blood flow to these organs, causing the severe clinical symptoms associated with this infection, such as cerebral malaria.

More details on the exact biochemical mechanisms for sequestration and its effect on the pathology of the infection can be found on the Tulane University website.

 

Does all malaria kill without treatment?

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QUESTION:

Does all malaria kill without treatment?

ANSWER:

No. There are five main species of malaria which infect humans: Plasmodium falciparum, P. vivax, P. ovale, P. malariae and P. knowlesi. Of these, P. falciparum is the most deadly, and can often cause death if left untreated.

The other four may also result in death, but more rarely, and usually only in high risk individuals, such as young children, pregnant women and people with weakened immune systems. Given the seriousness of the symptoms and the possibility of death in all cases, it is very important to seek medical advice if you suspect you have malaria. Once given accurate diagnosis of which type of malaria you have, you can be given appropriate treatment.

Incubation Period for Malaria

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QUESTION:

What is the incubation period of malaria?

ANSWER:

That depends on the species of malaria. Plasmodium falciparum has the shortest incubation time, typically 10 to 14 days. For P. vivax, incubation is usually between 10 to 17 days, but can be much longer (up to a year; the longest incubation time recorded for this species was 30 years!). P. ovale has an incubation period similar to that of P. vivax, and can also be dormant for many months or even years. P. malariae is thought to have an incubatiom time of between 16-59 days.

Will malaria come back?

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QUESTION:

As a result of a blood test I have just been informed that at some time I have had malaria. Though I have no idea when this was. I once was ill for 4 days with what I thought was flu and that is the only occasion I can remember. Therefore I have never been treated for malaria. Could you please tell me if there is any chance the disease will come back.

ANSWER:

That will depend on the type of malaria you had. I presume you found out you were infected through a blood test – it is likely a test that looked for antibodies to malaria in your blood. These tests can sometimes differentiate between the different species of malaria, and so it is definitely worth asking the clinic or doctor that performed the test if they can give you this information. Your location, or places where you have travelled in the last 4 years, may also assist in determining which type of malaria you had. Given that you barely registered being sick, I would suspect that you probably didn’t have Plasmodium falciparum, which is usually the most severe kind; it also cannot survive dormant in your system for long periods of time, so if you happened to have this kind, you wouldn’t need to worry about it coming back (though of course you can still be re-infected by all types of malaria, so prevention is still important!).

However, the other three main types of malaria can linger in a patient’s body. P. malariae is the least acute of all the malaria species, and can survive for a long time in the bloodstream, meaning that some people can have the infection for long periods of time without really feeling sick. If the blood test you took looked directly for parasites in your blood, and you tested positive, it is likely you have this kind. Like all uncomplicated cases of malaria, it is easily treatable, and once cured, you won’t have worry about it coming back (again, you do still need to watch out for being bitten by mosquitoes and getting re-infected though!).

The final two types of malaria are P. vivax and P. ovale. These persist in the body in a slightly different way than P. malariae – these have a special life stage which can lie dormant in the liver. Months or even years later, these dormant stages can re-activate and enter the blood stream, causing the patient to feel symptoms again, such as fever and nausea. Therefore, if you find you tested positive for one of these two forms, it is very important to ask your doctor about receiving medication (called primaquine) that will specifically target the liver stages of the parasites, to ensure you don’t get a recurrence of the infection later on.

As I’ve mentioned a couple of times earlier in this response, a key thing to be aware of is that even if you don’t have a recurring form of malaria, or treat it successfully, you will still be susceptible to re-infection if you are bitten by an infected mosquito. As such, if you live in or travel to a region known to have malaria transmission, it is crucial to take steps to prevent infection. For example, sleeping under a long-lasting insecticide treated bednet greatly reduces your risk of being bitten by the mosquitoes that carry malaria; similarly, wearing long-sleeved clothing and insect repellent, especially at night when malaria mosquitoes are most active, is recommended. Finally, medication is available that can be taken to prevent malaria (these are called prophylactics). As they can be expensive and are not recommended to be taken over long periods of time, these tend to be used primarily by people travelling to malarial areas rather than residents. There are several different forms of these prophylactics available commercially; the one to use will depend on several factors, including where you are travelling to.