Fever, headache are early malaria symptoms

This interactive health column appears in cooperation with the Singapore-based Parkway Group Healthcare. Readers are encouraged to ask questions through features@thejakartapost.com or direct to Parkway's san-san@gleneagles.com.sg. Following is from a paper by Dr. Oon Chong Teik.

SINGAPORE (JP): Malaria is transmitted by the bite of a female anopheline mosquito. The early symptoms are fever, headache, muscle ache, chills and the person infected usually has a history of travel to a malaria area.

The parasite lives in the red cells and multiplies every 12-24 hours. One parasite can divide into 8-l2 offspring, which are then liberated and infect other healthy red cells. In severe P. falciparum malaria or malaria tropica as it is known in Indonesia, the parasite lodges in and blocks blood vessels in the major organs, such as the brain, kidneys and lungs, preventing an adequate blood supply.

In severe cases, more than 10 percent of the red blood cells in the body are infected and if not recognized, treated or thought to be dengue, hepatitis, typhoid, or if drug treatment is not correct, the person becomes unconscious and the kidneys stop producing urine. The urine is often black in color.

The patient also starts bleeding because of low platelets (thrombosis). Infection is also common as malaria reduces immunity, resulting in pneumonia, infections from bacteria in the blood and so on.

Cerebral malaria kills 2-3 million people ever year. In 1997, there were 11 deaths in the United Kingdom from returning travelers.

Five deaths occurred in Singapore in 1998, with 405 reported cases. Up to now, in Singapore, there were 3 deaths in 2000, two patients, aged 26 and 29; one was a New Zealander. The other was a newspaper reporter aged 51 who contracted the illness in Batam Island.

I saw 46 cases of falciparum malaria between 1997-2000 at Mount Elizabeth Hospital. Of those, there were five cases of severe complicated cerebral malaria with multiorgan failure and coma. The patients were air evacuated to Mount Elizabeth for further care after treatment failure abroad.

These cases included a 49-year-old French female tourist in Sulawesi; a 33-year-old American male who had traveled in Cambodia and Sabah and Sumbawa in Indonesia; a 54-year-old Malaysian male oil worker contracted the disease in Sumatra, Indonesia, and was evacuated to a Malacca specialist center; a 43-year-old male Indonesian following a fishing trip in Sumatra; and a 54-year-old male Indonesian who had traveled to Timor island.

A patient with 2 percent parasites in the red blood cells is usually very ill, with an increased risk of death. Most of the patients had a parasite count of more than 10 percent, which is critical. The highest was 18 percent, but the French patient did not have any in her preliminary blood film. This was most likely due to malaria treatment before arrival at Mount Elizabeth, but can occur in severe cases as most of the parasites are "trapped" in the internal organs.

Infective hepatitis was initially suspected, as she was jaundiced. The diagnosis of falciparum malaria in this woman was confirmed by a special "dipstick" test in the blood. The Parasite F test, which detects a special protein produced by falciparum malaria, called histidine-rich protein 2 (HRP2), takes only five minutes to perform.

All the patients were in the intensive care unit and nearly all needed renal dialysis, mechanical respirator treatment and blood platelet transfusion. The patients also needed multiple antibiotics for chest infections.

The American patient had a severe bleeding tendency and needed almost 70 units of blood products. All the patients developed fluid in the lungs (pulmonary oedema). The Malaysian patient developed superficial gangrene of his toes as well as a resistant staphylococcus aureus chest infection (MRSA).

Specific treatment was with Artesunate (Qinghaosu), a herbal medicine known in China for 2000 years for treating fevers and was "rediscovered" in 1971. The drug is extracted from the leaf of the Chinese weed Artemisia annua or sweet wormwood. It is also used as a flavoring in vermouth and in floral decorations for its fragrance. It is a very effective antimalarial, shortens coma, fevers, acts rapidly against the parasite and no toxic side effects have been detected in the doses used. It is as effective as quinine, which has some side effects. As the malarial parasite develops resistance to Artesunate if used alone, Dr Oon combined it with Mefloquine.

There were no relapses in all 46 falciparum malaria and the five severely ill patients and all made full recoveries with no residual neurological damage, or damage to the kidneys and lungs. Blood counts returned to normal and they all walked out of hospital alive after being at Mount Elizabeth Hospital for about a month.

It is recommended that the public and medical students be educated about the seriousness of the disease. If diagnosed early and treated with the appropriate antimalarials, it is easily cured. Patients should also consult their own doctors regarding medication to prevent malaria (prophylaxis) during travel and concerning the use of mosquito repellents. Medical management must be multidisciplinary, coordinated and handled by doctors familiar with the disease.

--This paper was presented at Mount Elizabeth Hospital's 1st Annual Clinical Meeting on 13th August 2000 in Singapore.