Malaria or Kidney Infection?

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QUESTION

Two months ago my daughter was in Uganda working and when came back to the States she was hospitalized for 4 days with Malaria symptoms. Her tests came back negative they really didn’t act like they knew how to treat this. They kept telling her they didn’t know how to diagnosis Malaria. So they treated her for it. She now after 2 months is once again hospitalized with the same symptoms. They are telling her they think it is a kidney infection. Can malaria be misdiagnosed as a kidney infection. She once again has all the symptoms as malaria?

ANSWER

What tests did the doctors do to try to diagnose malaria in your daughter when she first got back to the States? Usually, malaria is diagnosed by a blood test, whereby a trained technician will look at the patient’s blood under a microscope. The technician looks for signs of the malaria parasite in the patient’s blood, and if seen, can determine the intensity of the infection as well as the species of malaria. This is important information for accurate treatment. Alternatively, rapid diagnostic tests, which utilize a droplet of blood in a device which looks similar to a pregnancy test, and can very quickly determine whether someone is infected with malaria. It is important to know that malaria cannot be diagnosed by looking at standard blood parameters. If you don’t think your doctors know what is afflicting your daughter, you should take her to a clinic which specializes in tropical or travel medicine. There, they will certainly know how to effectively diagnose your daughter.

Given that your daughter experienced a resurgence of symptoms two months after returning, if she did have malaria, then there are two kinds which she might have: Plasmodium ovale and Plasmodium vivax. The other types of malaria, including the most deadly kind, P. falciparum, are not able to come back and relapse once they are treated. However, in order to prevent future relapses, your daughter may also have to be treated with another form of medication called primaquine. I will emphasize again, however, that it is crucial to gain an accurate diagnosis before taking any form of treatment for malaria.

Malaria in Pakistan

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QUESTION

4 years ago I traveled to FATA Pakistan and in every year in the month of August I caught malaria. Last few days I feel much Headache and fever in the evening and go to doctor. He diagnosed malarial parasites in blood and has advised me take tab artem ds 2 BD for three days after complete the course I feel same headache fever with shivering. Please recommend something.

ANSWER

I am not sure which malaria treatment you have taken—was it just artemisinin, or a combination drug which also included another anti-malarial? The latter type is what is recommended by the World Health Organization (WHO); treatments only containing artemisinin are very effective short term, but can sometimes leave a few parasites alive at the end of the course, which not only may result in a recurrence of symptoms (known as recrudescence) but is very bad in terms of leading to drug resistance in the malaria parasite. However, it is also possible that you are merely experiencing some slight side effects to the medication you took; often these mild side effects are very similar to the symptoms of malaria! If you don’t feel better in a few days, it might be worth visiting the doctor again to check that you don’t still have malaria parasites in your blood.

Malareich and Pregnancy

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QUESTION

Hi , am 31 weeks pregnant and had to take Malareich as my Anti malaria drug. I did not take the drug until I felt I had malaria, because I had body pains and headaches. Please advise if I will be ok after taking the malareich.

ANSWER

Malareich is a combination drug comprising of sulfadoxine and pyrimethamine, which is one of the medications recommended for treatment of malaria in pregnant women. However it sounds like you took the medication because you thought you had malaria – it is really important to be diagnosed by a doctor. For example, they will be able to ensure that you get the correct type of treatment for the kind of malaria you have. Malareich, for example, is probably not as effective against P. vivax malaria as P. falciparum malaria, but P. vivax is still susceptible to chloroquine, which is another drug that is suitable for the treatment of malaria in pregnant women.

Recurrence of Malaria Symptoms

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QUESTION

If a person suffering from malaria is given the proper treatment and he gets well but he again develops the symptoms of malaria..? These symptoms would arise from liver or blood? Who’ll be responsible for the recurrence of the symptoms?

ANSWER

Malaria can come back in three ways: first of all, the person could have been successfully treated, but then re-infected again by being bitten by an infected mosquito. In these cases, the person should focus on improved malaria prevention, such as sleeping under a long-lasting insecticide treated bednet.

Secondly, the patient could have recrudescence: when the patient takes medication, the treatment kills most of the malaria parasites in the blood, and enough so the patient feels better again, but some parasites still remain. Then, after the treatment finished, the parasite is able to replicate again, they increase in number in the blood and the patient feels ill again. In this case, you would say the infection came back from the blood, and the patient should take another dose of anti-malarials, but of a different kind to that which they originally had, in order to kill all of the parasites.

Finally, there is what is called relapse, which only occurs with two types of malaria: Plasmodium vivax and Plasmodium ovale. These are able to form dormant stages in the liver, so even when all the parasites are killed in the blood by the malarial treatment, these dormant forms survive. Many weeks, months or even years later, these dormant liver stages can re-activate and enter the blood again, causing new malaria symptoms. In this case, the liver was the source of the parasites. Again, the active blood infection should be treated with anti-malarials, but the patient should also talk to their doctor about taking primaquine, a drug which can kill any remaining dormant liver forms and thus prevent future relapses.

Community Based Management for Malaria

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QUESTION

what are the methods for community based management for malaria?

ANSWER

Community-based management of malaria revolves around three main principles: prevention, diagnosis and treatment.

Prevention mainly revolves around stopping mosquitoes from biting people. Methods for this include distribution of long-lasting insecticide treated bednets (and teaching people to use them properly!), indoor residual spraying to stop mosquitoes from living in houses, screening houses properly and removing sources of stagnant water from the community to stop mosquitoes from breeding. Collectively, these methods are considered “vector control”. They have benefit for the individuals who practice the methods, as well as collective benefit at the community level from reduced transmission. Within the community, pregnant women and young children, who are most at risk of severe infection, are often targeted for preventive measures. In addition, transmission of malaria from a pregnant mother to her unborn child can be prevented through chemoprophylaxis, administered usually twice during pregnancy, in a process known as intermittent preventive therapy (IPT).

Diagnosis and treatment involves educating people about the symptoms of malaria so that if they suspect they are infected, they know how and where to seek appropriate medical care. The community therefore has to provide a clinic or hospital that is sufficiently equipped to do accurate diagnosis, which requires blood testing. Clinicians should also be able to identify which type of malaria the patient is infected with, since this determines treatment. Identification of the type of malaria is usually done via looking at the blood of the patient under a microscope, a process which requires a significant amount of training. The type of treatment depends on the severity of infection as well as the type of parasite they are infected with.

All of the above interventions depend on sustained investment in community health care, training of local health workers and clinicians and education the community about the transmission of malaria and how this can be interrupted.

Malaria Diagnosis

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QUESTION

How to identify malaria? My son has fever and headache for the past three days and also vomiting. Is treatment is necessary and what type of treatment he needs?

ANSWER

You need to take your son to the doctor or to a clinic where they can do a blood test to look for malaria. They will either look at his blood under a microscope or use his blood in a “rapid diagnostic test” (RDT), both of which can identify the presence of the malaria parasites in his blood. If he is positively diagnosed with malaria, then your son should receive treatment, probably a type of artemisinin-based combination therapy (ACT) – common brands include Coartem, Lonart and Alu (though there are many others). These are what the World Health Organisation recommends as first line treatment against non-severe malaria.

Given your son’s symptoms, you should certainly go for a malaria test, just in case. However, vomiting is not usually a symptoms associated with malaria, so it is also possible he has another infection, such as an intestinal parasite, or even a bacterial or viral infection. Unfortunately, the symptoms of malaria are very general, so you really need to have one of the blood tests I mention above in order to be sure that your son has malaria.

Malaria Test – Can Malaria Return?

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QUESTION

I am working in Tanzania. I felt sick about 10 days ago and I went for a test for malaria and the test was positive. The doctor gave me some pills and said I must come back in one week for a test again. I went back and it was negative but now I don’t feel too good. Is it possible for the malaria to come back after 10 days?

ANSWER

It is unlikely that the malaria has come back, and if your malaria test is negative, then you probably don’t have malaria any more, and you can be confident the treatment worked. It sometimes takes a few days or even a couple of weeks to fully recover from the infection, since it takes quite a toll on the body’s immune system. Also, the medication you take to treat malaria can also have side effects, such as nausea and headaches, which actually seem similar to the symptoms of malaria itself.

Malaria Fever and Recovery

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QUESTION

My 21 year old daughter spent 4 months on a study abroad program in Dakar. A week before returning home she started having night fevers and would complain of retrosternal pain and rib and neck and shoulder pain. The next day she would be fine.

The episodes came every other day and eventually it occurred to her that it might be malaria. It was evening so she went to a pharmacy for a rapid diagnostic test which they didn’t have but they felt she had malaria based on her symptoms and gave her a 3 day course of artesunate-mefloquine.

She returned to the United States and a day after taking her last dose, she was seen by a physician and tests were done which showed that she had contracted Plasmodium falciparum malaria. Other than the smears, all her lab tests and CXR were normal and there were no abnormal findings on physical exam, in fact she was the picture of health.

We were told that she was cured and that no follow up was necessary and that she could continue with her planned trip to Thailand the next day. About 6 hours before boarding the plane to Bangkok she developed fever of 100.9 but had absolutely no other symptoms or pain. About an hour later she had a bout of diarrhea. She had one more low grade fever on the flight (99.8). I spoke to another physician who seems more familiar with malaria and was told that she is not actually cured and may continue to have episodic fevers and symptoms for a while or it’s possible she was just suffering from an ordinary garden variety gastrointestinal bug.

I have many questions. I understand that her malaria is the most virulent type. How is it that all her lab work and physical exam is normal 1 day after completing treatment? Can we expect it to remain normal? What causes the episodic fevers if she is supposedly cured? She is on doxycycline again prophylactically (which she was on in Senegal) while in Thailand. Should she be on something else since she did contract malaria on doxycycline? (She took it religiously). Thanks for any advice. She will be seeing a physician in Bangkok ASAP, but since I won’t be there to ask questions, I am hoping you can give me some answers. Your site is the best information I have found on malaria.

ANSWER

Many thanks for the comprehensive information you have provided regarding your daughter’s condition. Even though your daughter did have the most virulent form of malaria, she was very smart to seek treatment relatively promptly, and lucky to receive appropriate medication (artemisinin-based combination therapies, such as artesunate-mefloquine, are recommended by the World Health Organization as first-line treatment against malaria). It is likely due to this prompt and effective action that her lab tests and blood parameters were all normal so soon after treatment; had she waited longer for treatment, the consequences could have been much more severe. No resistance to this medication has been detected in Africa as of yet, so she should be fully cured and thus her health should remain stable; a blood smear, where her blood is examined under a microscope, can determine this; this is a very standard procedure so could easily be carried out in Thailand if she wants.

Fever is a side effect of the body’s immune system responding to a disease threat, so it is not uncommon for some symptoms to carry on after treatment. In addition, mild side effects of anti-malarial medication can often mimic the symptoms of malaria itself, including fever and nausea.

Given also the (entirely reasonable) possibility of an additional, unrelated stomach bug, I suspect that your daughter has successfully beaten off this malaria attack, and while she should remain vigilant if similar symptoms arise again, her health in the future should not be adversely affected at all by this episode.

Also, as mentioned briefly above, medical professionals in Thailand should be well equipped to diagnose and treat malaria if she suspects she has been reinfected. It is worth noting that malaria in south-east Asia has shown signs of resistance to mefloquine (as well as other drugs, such as chloroquine and sulfadoxine-pyrimethamine), so if she does require treatment while there, she should make sure the medication they provide does not contain any of the afore-mentioned compounds.

Regarding doxycycline, it’s great that your daughter took it religiously—that is certainly the first step towards protection. Randomized placebo controlled trials have shown it is between 92-96% effective in preventing P. falciparum malaria, which is very good, but obviously not 100% perfect – even when taken perfectly, some infections do occur. In addition, there is some data which suggests that dairy products, taken together with doxycycline, may limit  the uptake of the drug. This is rarely communicated to patients, who are instead contrarily told sometimes that taking the pills together with dairy products can reduce side effects! As such, please let your daughter know that she should avoid dairy products for 2-3 hours around the time she takes her doxycycline.

Untreated Malaria

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QUESTION

If I am infected with malaria and I get a wrong diagnosis and be treated for flu, can the other symptoms disappear but continue to experience severe headache especially on the right side temple and jawbone area combined with general weakness and numbness in the legs?

ANSWER

Certainly the symptoms of malaria can often be confused with other infections, including flu. Given that treatment for flu will often include anti-fever medications such as aspirin or paracetamol, these drugs may also ameliorate some of the symptoms associated with malaria, without actually curing them.

However, numbness in the legs is not usually characteristic of malaria infection, though headache and weakness could be—again, these are general symptoms of many other infections as well.

If you suspect you have been misdiagnosed and have malaria, you should ask your doctor for a blood test; these can also be carried out at any local hospital or clinic. There, by looking at your blood under a microscope or using it in a rapid diagnostic test, they will be able to determine accurately whether you have malaria.

Diagnostic Blood Test: Malaria in Nepal and India

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QUESTION

My daughter has returned from a 6 week trip to Nepal and then India. About 20 minutes into the flight home she developed pains and aches in her hips and legs, fever, generally feeling dreadful but no nausea or diarrhea. When she arrived after the 10 hour flight her temperature was 100.5. We were concerned about malaria, but when she saw her primary care doctor the next morning she felt much better and her temperature was normal.

Blood taken at that visit showed no sign of malaria, but the doctor said that she could develop a recurrence in 3-4 weeks time when blood test should be repeated to confirm malaria if present.

I don’t doubt her doctor, but do these symptoms suggest malaria? How common is it for an initial episode of malaria to show up as negative on blood tests? She started taking tablets 3 days before entering a high risk area and took them for 3 weeks, but stopped during a brief diarrheal illness and did not restarted her anti malaria tablets.

ANSWER 1 – From Malaria.com Editor:

I think your GP might be mistaken about this – the only way to diagnose malaria is through a blood test which is positive for the disease! I have never heard of any cases where the initial blood test is negative, followed by a positive recurrence several weeks later. There are cases were the initial level of infection is quite low, in which case sometimes the parasites can be missed when looking at the blood film; however, when symptoms are present, this is rare. Moreover, there is no biological reason for a recurrence in several weeks; usually, reoccurrence occurs when treatment is given and for whatever reason is unsuccessful, allowing the malaria parasites to come back (and this assumes they are positively observed in the first place!).

Another diagnostic option, if you want to double check, is to see if you can find a rapid diagnostic test for malaria, which uses a drop of the patient’s blood to look for proteins produced by the malaria parasite. Similarly, there are tests which look for antibodies against malaria; this kind of test, known as serology, is not good for diagnosing active infections since antibodies can persist after the infection has been cleared, but may give you an indication of whether your daughter was exposed to malaria at all during her time in Nepal. Both of these are even more sensitive than blood smears, and although not as common as blood smears, are available in many places, particularly through hospitals which have tropical medicine departments or experts. All in all, if your GP is insisting on a second malaria test in a few weeks, by all means there is no harm in doing that, but in the meantime I would seek a second opinion since I think it is more likely your daughter has another infection (possibly a gastrointestinal bug, or a viral infection) which may risk going undiagnosed if your GP fixates on malaria as the answer.

Regarding the symptoms, unfortunately the symptoms of malaria are very general and it is almost impossible to accurately diagnose the disease on the basis of symptoms alone, hence why a blood test is so important. The blood test, with positive observation of the malaria parasites, is also crucial to determine which species of malaria the patient has, which may have implications for the appropriate treatment.

Answer 2: From Malaria.com Medical Advisor (MD)

The diagnosis of malaria should always be considered for patients with a fever who have traveled to malaria endemic areas. Your concerns that this may be malaria are well founded. Malaria symptoms in the first few days of infection are similar to the early stages of many other febrile illnesses, including viral and bacterial infections. In malaria, the fever also typically waxes and wanes in the manner you described. Confirming the diagnosis requires detecting parasites or their products in a blood sample. The most common test involves inspecting blood under a microscope for the presence of malaria parasites. Sometimes early in the disease there aren’t enough parasites for detection by this method. For this reason, several blood smears taken at 12-24 hour intervals are sometimes required to rule out a diagnosis of malaria in a symptomatic patient.

Additionally, your daughter was vulnerable to infection because she stopped taking antimalaria medicines while traveling in a region of malaria risk. To offer protection, these medicines must be taken for the duration of the stay, and depending on the medicine, up to 4 weeks after the last possible malaria exposure.

Unfortunately most medical doctors in regions where malaria is very rare, like the the United States and Europe, have little experience diagnosing and managing malaria. I would advise you to seek attention at a travel clinic or infectious disease specialist without delay, where it is likely further blood tests will be undertaken immediately to establish laboratory confirmation, and the prompt initiation of treatment for malaria if present.