PART 1

A 42-year-old woman presents to her primary care physician with a 2-day

history of fever, chills, and sweats with associated headache and myalgia.
She is febrile (38.6C [101.4F]) and tachycardic, but examination is
otherwise unremarkable. On examination she appears ill, with a
temperature of 38.8C (101.8F), pulse rate 120 bpm, BP 105/60 mmHg,
and mild jaundice. Further history reveals that she recently visited family
in Nigeria for 2 months, returning 1 week before presentation.
(a) What is the MOST likely diagnosis? (1 mark)
Malaria
(b)Name five organisms.
Plasmodium vivax Plasmodium ovale Plasmodium malariae
Plasmodium knowlesi Plasmodium falciparum
(c) State three (3) risk factors for severe disease besides the species of the
organism.
Low host immunity (i.e., individuals living in non-endemic areas)
Pregnancy
Age <5 years
Immunocompromise (e.g., underlying HIV infection)
Older age.
(d)State TWO protective factors for malaria.
G6PD deficiency
Sickle cell trait
Melanesian ovalocytosis
HLA B53 allele
(e) Describe the pathophysiology for the diagnosis you have stated in (a).
(4 marks)
During a blood meal, an infected female Anopheles (1/2) mosquito
injects 8 to 15 malarial sporozoites (1/2), which rapidly enter
hepatocytes
Reproduction by asexual fission (1/2)(tissue schizogony) takes place
to form a pre-erythrocytic schizont
Thousands of merozoites are released into the bloodstream to
penetrate erythrocytes after attaching via receptors (1)
Merozoites undergo blood schizogony to form trophozoites, evolving
to schizonts, which rupture to release new merozoites (1)
Rupture of erythrocytes releases toxins that induce the release of
cytokines from macrophages, resulting in the symptoms of malaria
(1)
(f) State ONE gold standard test for confirmation of malaria. List seven(7)
other investigations with justification(s)/expected finding(s) that you
would like to request in this woman.
Investigations
Giemsa-stained
thick and thin
blood smears

Justifications
Sensitive for detecting malarial parasites than
thin films, as the blood is more concentrated
which allow for a greater volume of blood to be

Full blood count

Coagulation
profile
Renal function
test

Liver function
test
Arterial blood
gas

Urinalysis

Random blood
sugar
Blood culture

examined.
Identification and calculation of the parasitaemia
(percentage of parasitised red blood cells).
Necessary to determine appropriate treatment.
High parasitaemia (>2% of erythrocytes
parasitised) is a sign of more severe disease
Low platelet count secondary to consumptive
coagulopathy
Variable white blood cell count
Anemia
Elevated prothrombin time
Elevated urea and creatinine due to pre-renal AKI
Renal failure may develop due to microvascular
obstruction, filtration of free haemoglobin and
myoglobin, volume depletion, and hypotension,
with reduced urine output and proteinuria.
Elevated unconjugated bilirubin and
aminotransferase
Metabolic acidosis/lactic acidosis in severe
disease
Tissue hypoxia due to microvascular obstruction,
impaired red cell deformability, anaemia,
hypovolaemia, and hypotension can lead to lactic
acidosis, which may contribute to impaired level
of consciousness.
Massive haemolysis combined with acute tubular
necrosis produce acute renal failure with
haemoglobinuria and proteinuria.
May show trace to moderate protein;
urobilinogen and conjugated bilirubin may be
present
Hypoglycemia / hyperglycemia
Hypoglycemia secondary to quinine therapy
To rule out septicemia

(g)What are the laboratory findings associated with severe malaria. Name
three (3) such laboratory findings.
Hypoglycaemia (blood glucose < 3.0 mmol/l)
Metabolic acidosis (plasma bicarbonate < 18 mmol/l)
Severe normocytic anaemia (Hb < 8 g/dl, packed cell volume <
24%)
Haemoglobinuria
Hyperparasitaemia
(> 20,000/l for P. knowlesi or > 100,000/ l for other Plasmodium
species)
Hyperlactataemia
Renal impairment
Candidates are not expected to quantify the laboratory results
above.
(h)What are the clinical features associated with severe malaria. Name 3
such clinical features.
Impaired consciousness or unrousable coma
Prostration (generalized weakness so that the patient is unable to
walk or sit up without assistance)
Failure to feed/ not tolerating orally
Convulsion
Deep breathing, respiratory distress (acidotic breathing)
Circulatory collapse or shock, systolic blood pressure < 90 mm Hg
(**please refer to physician for local figure) in adults and < 50 mm
Hg in children
Clinical jaundice and evidence of other vital organ dysfunction
Haemoglobinuria
Abnormal spontaneous bleeding
Pulmonary oedema (radiological)

(i) A diagnosis of malaria was made. Enumerate 6 acute and 2 chronic

complications of malaria.
Acute complications
Cerebral malaria
Acute renal failure
AKA Black water fever (triad of
severe hemolysis,
hemoglobinuria and renal
failure)
Hypoglycemia (failure of hepatic
gluconeogenesis or quinine
therapy)
Non-cardiogenic pulmonary
edema
Acidosis
Hematological abnormalities
DIC
Algid malaria Severe malaria
with cardiovascular collapse
ARDS
Acidosis
Splenic rupture (distinction)

Chronic complications
Tropical splenomegaly
Quartan malarial nephropathy
(Distinction)

(j) For each of the complication stated above, describe the principle(s) of
management.

(k) Enumerate five (5) clinical features of cerebral malaria.

Decreased LOC
Fever
Seizures
Contracted or unequal pupils, retinal hemorrhages, papilloedema,
discrete spots of retinal calcification
(l) Describe the principles of primary prevention of malaria.
Avoid outdoor activity after unsent
Using insect repellants
Wearing long sleeved shirts and pants
Use insecticide-treated bed nets
Antimalarial prophylaxis
Importance of chemoprophylaxis
Potential adverse reactions or side effects from
chemoprophylaxis
Counseling
Clinical manifestations of malaria
Plan for urgent medical care
Assess malaria risk
Determine malaria resistance patterns
Consider the following:
Age
Underlying medical conditions
Chemoprophylax Allergies
is
Tolerability
Length of stay
Advise when to start medication and how long to
continue after return
Determine whether medication should be prescribed for
presumptive self-treatment
Minimize outdoor activity at dusk, nighttime
Wear long sleeves, long pants, and hats at dusk,
nighttime
Use insect repellent:
Personal
10% to 35% N,N-diethyl-3-methylbenzamide for exposed
protective
skin
measures
Permethrin for clothes, shoes, mosquito nets, tents, and
other gear
Insecticide-treated bed nets
Mosquito coils and candles
(m) Describe the principles of malaria
Notify within 7 days
Paracetamol for fever / Tepid sponging
Transfuse if severe anemia. Consider exchange transfusion if the
patient severly ill.
Monitor TPR, BP, urine output, and blood glucose frequently.
Daily parasite count, platelet, urea and electrolytes and LFT
Identify the organism/species.
Start antimalarial agents based on the local resistance patterns
Monitor for complications

Review the need for admission to ICU

Discuss with ID specialist
Strict I/O chart
P ovale and P vivax, this is followed by primaquine to eradicate
the hypnozoites and avoid relapses
(n)Name five (5) contraindications to chloroquine.
Hypersensitivity to quinine, mefloquine, quinidine, or any other
component
Prolonged QT interval
Glucose-6-phosphate dehydrogenase (G6PD) deficiency
Myasthenia gravis
Optic neuritis

Shown
Plasmodi
Plasmodium
Plasmodi
um
Plasmodi Plasmodi
knowlesi
um
falciparu um vivax um ovale
malariae
m
Asexual
72
cycle
48 (tertian) 48 (tertian) 48 (tertian)
(QUARTAN)
(hours)
Relapse
No
YES
YES
No
Chloroquin
e
YES
Rare
No
No
resistance
Rings
predomina
Oval RBCs
te, multiply
Trophozoit
Enlarged
with
infected
e
RBCs,
fringed
RBCs, high
cytoplasm
Schffners edges,
parasitemi
compact
dots,
Schffners
a, rings
(band
Characteris
trophozoite
dots,
with
forms), 6tic on thin
cytoplasm trophozoite
thread-like
12
blood film
ameboid, cytoplasm
cytoplasm,
merozoites
12-24
compact,
double
in mature
merozoites
6-16
nuclei,
schizont,
in mature merozoites
bananaRBC
schizont in mature
shaped
unchanged
schizont
gametocyt
es

24 (tertian)
No
No

Similar to P.
malariae , 8-10
merozoites in
mature
schizont, often
in rosette
pattern with
central clump
of pigment