Although Ebola has been all the furor in the recent weeks, fever in travelers is NOT Ebola most of the times. Depending on the region and season, the usual culprits are more likely than Ebola, these include malaria, dengue, yellow fever, chikungunia virus, hepatitis, salmonella and other intestinal bugs, multiple parasites among others. Here is the Q&A for malaria and babesia from this month's NEJM.
What
is the annual incidence of malaria in the United States?
In the
United States, the annual incidence of malaria is approximately 1500 cases.
In 2010, a total of 1691 cases were reported to the Centers for Disease
Control and Prevention (CDC), the largest number reported since 1980; P.
falciparum, P. vivax, P. malariae, and P. ovale were identified in
58%, 19%, 2%, and 2% of cases, respectively.
How
do malaria and babesiosis differ in appearance on a peripheral blood smear?
Intraerythrocytic
parasites are seen in both malaria and babesiosis. Plasmodia metabolize heme
to form an intracellular crystallized pigment, hemozoin. Although hemozoin is
not invariably identified in cases of malaria, its presence reliably
distinguishes malaria infection from babesia infection. Malaria parasites can
be distinguished from B. [Babesia] microti by the
presence of recognizable gametocytes (characteristically banana-shaped in Plasmodium
falciparum and round, with a granular appearance, in nonfalciparum
species). In addition, intracellular vacuoles and extracellular merozoites
are unusual in malaria but common in babesiosis, and the classic “Maltese
cross” (a tetrad of parasites budding at right angles) is unique to babesia
species.
Which malaria species can remain dormant in the
liver?
In the
case of P. vivax and P. ovale, some sporozoites
(immature malaria parasites) do not replicate immediately when they invade
hepatocytes but remain dormant (as hypnozoites) for prolonged periods. The
average time to relapse is approximately 9 months, but it can range from
weeks to years. The interval to relapse depends on the strain (earlier with
tropical strains and later with temperate strains), the initial inoculum, and
host factors (e.g., febrile illnesses can trigger relapse associated with P.
vivax). None of the commonly used prophylactic agents (chloroquine, mefloquine,
doxycycline, or atovaquone–proguanil) eliminate hypnozoites. Primaquine, the
only effective drug against dormant hypnozoites, has not been approved by the
Food and Drug Administration for primary prophylaxis, but the CDC endorses
its use for prophylaxis in Latin American countries where P. vivax
predominates, because the drug can prevent both primary attacks and relapses
caused by all species that are a source of malarial infection.
How is acute or recurrent P. vivax infection treated?
In patients
with acute or recurrent malaria infection, treatment depends on the species
and the resistance status in the area where the infection was acquired. P.
falciparum is resistant to chloroquine in most regions in which it is
endemic and resistant to mefloquine in parts of Southeast Asia. In contrast,
nonfalciparum malaria parasites do not have substantial resistance to
mefloquine, and the distribution of chloroquine-resistant P. vivax
malaria is limited, occurring primarily in Indonesia and Papua New Guinea.
After treatment is initiated, peripheral-blood smears should be obtained
daily for 4 days (parasitemia is typically eliminated by day 4), on days 7
and 28 to confirm eradication, and at any time symptoms recur, suggesting
treatment failure. In areas other than those with known chloroquine
resistance, chloroquine, followed by a 14-day course of primaquine to prevent
subsequent relapses, remains the standard treatment for P. vivax
parasitemia. Given the risk of hemolysis in patients with glucose-6-phosphate
dehydrogenase (G6PD) deficiency who receive treatment with primaquine,
potential recipients should be tested for G6PD deficiency. Among patients
with a contraindication to primaquine therapy, treatment with chloroquine
alone carries a 20% risk of relapse; extended chloroquine prophylaxis can be
offered to patients who have frequent relapses.
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Thursday, November 6, 2014
Malaria - Quick review
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