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CHAPTER 78: Severe Malaria 721

procedures that will increase the likelihood for disease transmission. • Freedman DO, Weld LH, Kozarsky PE, et al. Spectrum of disease
This puts both HCWs and other patients at risk for acquiring disease and relation to place of exposure among ill returned travelers. N
as experienced during the SARS epidemic, the H1N1 pandemic, and Engl J Med. 2006;354:119-130.
other outbreaks of highly contagious disease. Therefore, a standardized
approach, with early isolation and testing of these cases, can reduce the • Guery B, van der Werf S. Coronavirus: need for a therapeutic
likelihood of disease transmission of an emerging pathogen within the approach. Lancet Infect Dis. 2013;13:726-727.
ICU. Figure 77-1 outlines an approach to early isolation, testing, and • Kirkland KB, Wilkinson WE, Sexton DJ. Therapeutic delay and
involvement of institutional infection control and public health in cases mortality in cases of Rocky Mountain spotted fever. Clin Infect
of acute febrile illness with respiratory failure admitted to the ICU. Dis. 1995;20:1118-1121.
Upon admission, a critically ill traveler should undergo initial diag- • Leder K, Torresi J, Libman MD, et al. GeoSentinel surveillance
nostic testing as discussed earlier. If an etiologic agent is identified on of illness in returned travelers, 2007-2011. Ann Intern Med.
initial screening and clinical findings (ie, gram-positive diplococci with 2013;158:456-468.
a lobar pneumonia on x-ray), targeted treatment and ICU admission
are performed with appropriate isolation based on pathogen. However, • Sebbane F, Jarrett CO, Gardner D, Long D, Hinnebusch BJ. Role
if an agent is not easily identified in a patient with acute febrile illness of the Yersinia pestis plasminogen activator in the incidence of
and respiratory failure, patients should be placed in isolation and distinct septicemic and bubonic forms of flea-borne plague. Proc
further diagnostic testing should be performed based on epidemio- Natl Acad Sci U S A. 2006;103:5526-5530.
logic risk. Isolation should most likely be droplet, but based on specific • Seto WH, Tsang D, Yung RW, et al. Effectiveness of precautions
epidemiological clues, airborne isolation may be instituted. Although against droplets and contact in prevention of nosocomial trans-
bronchoscopy generates aerosols and can increase transmission risk, mission of severe acute respiratory syndrome (SARS). Lancet.
it should not be avoid in these cases as isolation of the causative agent 2003;361:1519-1520.
becomes important from a public health perspective. • Simmons CP, Farrar JJ, Nguyen vV, Wills B. Dengue. N Engl J
Involvement of institutional infection control, microbiology, and Med. 2012;366:1423-1432.
public health services should be sought as early as possible. Usually this
is performed after the common agents have been eliminated and a suspi- • Sinclair D, Donegan S, Isba R, Lalloo DG. Artesunate versus
cious high-risk pathogen is suspected. Hospital-based infection control quinine for treating severe malaria. Cochrane Database Syst Rev.
will assist in isolation and HCW protection, and the hospital-based 2012;6:CD005967.
microbiology laboratory should be notified of suspected pathogens,
allowing for worker protection and targeted testing of samples. Finally,
public health involvement will allow a broader viral testing, including
additional agents, subtyping, and resistance testing. Early public health
involvement will allow for rapid laboratory testing, epidemiological REFERENCES
investigation, case definition, and community prevention. Finally, higher Complete references available online at www.mhprofessional.com/hall
risk procedures should be limited in these cases. Aerosol-generating pro-
cedures are most common in ICU patients with an acute febrile illness
and respiratory failure, and reducing unnecessary risky procedures will
reduce patient and HCW risk. However, these procedures should not be
avoided if needed. Appropriate PPE should be worn by HCWs at all time, CHAPTER Severe Malaria
and if worn properly, disease transmission is low risk. Most cases during
the SARS and avian influenza epidemic appeared to have occurred when 78 Sanjeev Krishna
HCWs did not wear the appropriate PPE. Arjen M. Dondorp

CONCLUSIONS
KEY POINTS
The critically ill traveler can provide a diagnostic dilemma for the clini-
cian given the wide array of causative agents. However, an approach of • Malaria should be excluded as a cause of fever in any febrile patient
early empiric therapy for select disease, followed by a thorough evalua- who has traveled recently to a malaria-endemic area, or who may
tion based on epidemiologic risk, provides a balanced approach for all have been infected by contaminated blood through transfusions,
critically ill patients. Severe malaria, rickettsial disease with multiorgan needlestick injury, or other methods of direct infection.
failure, and bacterial sepsis with multiorgan failure (meningococcus, • Immunity to malaria may be short lived, so that even those who
plague, tularemia) can respond to early antimicrobial therapy. For viral have been brought up in malaria-endemic areas can develop severe
syndromes such as MERS-CoV, VHF, and dengue, supportive care is disease when they return as travelers.
essential. For influenza, however, therapy with a neuraminidase inhibi- • Severe malaria is a medical emergency and ideally should be
tor is essential in the first 48 hours. Early isolation and HCW protection
should also be initiated until a diagnosis can be determined. managed by experienced personnel in an intensive care setting.
• Although Plasmodium falciparum is the most important cause of
serious malaria, P vivax and P knowlesi can also cause severe and fatal
KEY REFERENCES infections.
• Intravenous artesunate should be given as soon as practicable and
• Cauchemez S, Fraser C, Van Kerkhove MD, et al. Middle East alternative or additional diagnoses should be excluded.
respiratory syndrome coronavirus: quantification of the extent
of the epidemic, surveillance biases, and transmissibility. Lancet • Complications of malaria such as hypoglycemia, lactic acidosis,
Infect Dis. 2014;14:50-56. seizures, organ failure, and secondary infections should be diag-
• Dennis DT, Inglesby TV, Henderson DA, et al. Tularemia as nosed early by regular monitoring and managed aggressively.
a biological weapon: medical and public health management. • Malaria can be particularly severe in immunocompromised
JAMA. 2001;285:2763-2773. individuals including those who have been splenectomized.

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