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Updated: Jun 7 2019


Images falci gametocyte.jpg
  • Snapshot
    • A 25-year-old woman presents to the clinic with a one-week history of continuous high-grade fevers, myalgia, chills, and night sweats. She recently returned to the United States after volunteering with the Peace Corps in Nigeria. Her temperature is 103.2°F (39.6°C) and physical reveals a palpable spleen. A peripheral blood smear is shown.
  • Introduction
    • Epidemiology
      • geography
        • endemic throughout most of the tropics
        • disproportionately high burden of malaria in Sub-Saharan Africa
      • prevalence
        • WHO estimated 216 million cases of malaria in 91 countries in 2016
      • risk factors
        • exposure to Anopheles mosquitos, particularly at dusk and dawn
    • Pathogenesis
      • transmission
        • through bites of female Anopheles mosquitos
      • Plasmodium life cycle involves two hosts: human and Anopheles mosquito
        • human host
          • sporozoite stage
            • the Plasmodium-infected Anopheles mosquito inoculates sporozoites into the human host during a blood meal
            • sporozoites infect hepatocytes and mature into schizonts, which rupture and release merozoites
          • hypnozoite stage
            • for Plasmodium vivax and Plasmodium ovale, a dormant stage (hypnozoites) can persist in the liver and cause relapses
          • merozoite and trophozoite stage
            • merozoites undergo asexual multiplication in erythrocytes
            • merozoites reform to become trophozoites, which are ring-shaped
          • schizont stage
            • trophozoites undergo division to form large multi-nucleated schizonts
            • the schizont ruptures releasing merozoites
              • rupture of erythrocytes correlates with fever spikes
          • gametocyte stage
            • some parasites differentiate into sexual gametocytes, which are the form of the parasite that is ingested by an Anopheles mosquito
        • Anopheles mosquito host
          • oocyst stage
            • male and female gametocytes fuse in the stomach of the mosquito to form an oocyst
          • sporozoite stage
            • the oocyst divides into many sporozoites, which are then inoculated into the human host to begin the cycle anew
      • 4 main speces of Plasmodium cause malaria
        • Plasmodium falciparum
          • irregular fever patterns
        • Plasmodium vivax
          • 48-hour fever cycle
        • Plasmodium ovale
          • 48-hour fever cycle
        • Plasmodium malariae
          • 72-hour fever cycle
    • Associated conditions
      • occlusion of capillaries in the brain (cerebral malaria), kidneys, and lungs (Plasmodium falciparum)
  • Presentation
    • Symptoms
      • fever
      • headache
      • anemia
      • splenomegaly
    • Physical exam
      • palpable spleen
      • conjunctival pallor
  • Studies
    • Labs
      • Peripheral blood smear shows trophozoites and schizonts within erythrocytes
        • trophozoite ring form within erythrocyte
        • schizont containing merozoites
        • red granules throughout cytoplasm in erythrocytes seen with Plasmodium vivax and Plasmodium ovale
    • Making the diagnosis
      • most cases are clinically diagnosed
  • Differential
    • Babesiosis
      • differentiating factor
        • predominantly in northeastern United States
    • Trypanosomiasis
      • differentiating factors
        • lymphadenopathy, somnolence, coma
    • Borrelia recurrentis
      • differentiating factor
        • history of tick exposure
  • Treatment
    • Medical
      • chloroquine
        • used in areas with low drug resistance
      • mefloquine
        • used in areas with high rates of chloroquine resistance
      • atovaquone/proguanil or artemether-lumefantrine
        • used in areas with high rates of chloroquine resistance
          • first-line treatment for P. falciparum resistant to chloroquine
      • primaquine
        • used to kill latent hypnozoites in Plasmodium vivax and Plasmodium ovale infection
      • intravenous quinidine or artesunate
        • used in life-threatening situations
  • Complications
    • Cerebral malaria
      • complication of Plasmodium falciparum infection
      • parasitized erythrocytes occlude capillaries in the brain
    • Renal failure
      • complication of Plasmodium falciparum infection
      • parasitized erythrocytes occlude capillaries in the kidney
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