Clinical Practice Points
Quinidine gluconate, the only drug approved for treatment of severe malaria in the
United States, has substantial adverse effects and limited availability. In a program
administered by the Centers for Disease Control and Prevention, intravenous artesunate
seemed to be a safe and effective alternative to quinidine for the treatment of life-threatening
Use this paper to:
- Start a teaching session with a multiple-choice question. We've provided one below!
- Ask your learners how malaria presents. Who is at risk? What are possible complications?
Use the information in DynaMed Plus: Malaria (log on with your ACP member ID and password).
- How is malaria diagnosed? Invite a hematologist to review the blood smear of a patient
with malaria and to compare it with the smears of patients with other causes of hemolysis.
- How is malaria treated? Artesunate has been shown to be effective and is recommended
by the World Health Organization. Why is it not approved by the U.S. FDA?
- Ask what an Investigational New Drug (IND) is. Invite a clinical investigator familiar
with pharmaceutical trials to review the path a drug must follow to gain approval
for use in the United States.
- Ask who requires malaria prophylaxis for travel. What regimen should be prescribed?
Although herpes zoster vaccine is licensed for persons aged 50 years or older, the
Advisory Committee on Immunization Practices (ACIP) recommends it be used only in
persons aged 60 years or older. This analysis evaluated the cost-effectiveness of
herpes zoster vaccine versus no vaccination among adults aged 50 years. The results
support the ACIP recommendations.
Use this paper to:
- Review the clinical manifestations of herpes zoster.
- How is uncomplicated zoster managed?
- What are the possible complications of zoster, and who is at risk? When is intravenous
- Ask if your learners recommend herpes zoster vaccination to their patients? Which
ones? Is it available for administration in your practice? Why or why not? Use a recent study to read about the barriers to the vaccine's use in clinical practice. How is it
obtained and administered when not available at your practice?
This meta-analysis of 13 randomized trials examines the benefits and harms of adjunctive,
systemic corticosteroid therapy for adults hospitalized with community-acquired pneumonia
(CAP). It found that systemic corticosteroid therapy may reduce mortality by approximately
3%, need for mechanical ventilation by approximately 5%, and hospital stay by approximately
Use this study to:
- Ask your learners why steroids might be of benefit in CAP.
- Review the forest plots in the paper and its appendix. Review how each study's results
are displayed, how the study's “weight” relative to the others is reflected
in the size of its box on the plot, and what the diamond at the bottom tells you.
Ask what the diamond's peak and side edges represent (the meta-analytic estimate and
its confidence interval, respectively). Be sure your learners understand the importance
of the vertical line, demarcating the difference between positive and negative effects.
- What side effects were reported with the use of steroids? Will your learners treat
their hospitalized patients with CAP with steroids? Which ones? The editorialists discuss their planned approach pending additional studies.
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A 54-year-old man is evaluated in the emergency department for a 2-week history of
fever and chills occurring every 1 to 2 days. He also has a significant headache,
muscle pain, and intermittent diarrhea. The patient is an archeology professor who
returned 2 weeks ago from a 6-week “dig” in Thailand in Southeast Asia.
He received pre-travel prophylactic vaccinations, including combined hepatitis A and
B virus vaccines, as well as yellow fever, typhoid, and Japanese encephalitis vaccines.
In addition, he completed a regimen of mefloquine for malaria chemoprophylaxis.
On physical examination, he appears ill but is awake and alert. Temperature is 39.4
°C (102.9 °F), blood pressure is 100/62 mm Hg, pulse rate is 118/min, and
respiration rate is 20/min. Cardiopulmonary examination is unremarkable. There is
A complete blood count indicates a leukocyte count of 8900/µL (8.9 ×
109/L), a platelet count of 82,000/µL (82 × 109/L), and a hemoglobin level of 10 g/dL (100 g/L). He also has a mildly increased serum
indirect bilirubin level and elevated serum alanine and aspartate aminotransferase
levels. A peripheral blood smear is shown.
Against which of the following malaria species should treatment be initiated in this
A. Plasmodium falciparum
B. Plasmodium malariae
C. Plasmodium ovale
D. Plasmodium vivax
A. Plasmodium falciparum
A diagnosis of malaria should be considered in the differential diagnosis of travelers
returning from malaria-endemic areas who present with fever and a peripheral smear
indicating Plasmodium organisms in the erythrocytes.
Diagnose a returning traveler with malaria.
The most likely malaria species against which treatment should be directed is Plasmodium falciparum. Malaria should be considered the most likely cause of fever in any traveler returning
from a malaria-endemic area of the world. After Africa, Asia is the geographic destination
with the highest risk of imported malaria. P. falciparum causes most malaria cases diagnosed in the United States following travel. Although
mostly all cases occur in travelers who did not take any chemoprophylaxis or who were
not adherent to it, infection can still be contracted despite compliance with all
medical and preventive measures. In this instance, the patient spent time in Thailand,
one of the rare malaria-infested zones where mefloquine-resistant P. falciparum has been reported.
There are no pathognomonic clinical signs or symptoms of malaria. In general, the
signs and symptoms of uncomplicated malaria are nonspecific and infrequently occur
before 1 to 4 weeks after return from travel. Fever, present in 100% of patients,
may have a recurring cyclical pattern every 48 or 72 hours, varying according to the
specific Plasmodium species and corresponding to the synchrony of organism replication. However, classic
periodic malarial fever is most often absent in imported cases. Other common symptoms
include myalgia, headache, and gastrointestinal discomfort. The degree of anemia depends
on the duration of disease and degree of parasitemia. Although leukocyte counts may
be variable, thrombocytopenia is present in greater than 50% of patients. Kidney impairment
may also occur, the pathogenesis of which likely relates to hemolysis and erythrocyte
sequestration within the kidney circulation. The term “blackwater fever”
is given to the very dark urine secondary to significant hemoglobinuria sometimes
observed in patients with severe falciparum malaria. Moreover, overwhelming disease may occur in patients who have anatomic or
functional asplenia. The standard for malaria diagnosis is the Giemsa-stained blood
smear by light microscopy. P. falciparum can involve erythrocytes of any size and are characterized by ring forms, some of
which may be multiple, positioned along the periphery of the erythrocyte against the
inner surface of its membrane. Classic “banana-shaped” gametocytes,
if detected, can help to distinguish falciparum malaria species from the other potential Plasmodium species.
Infection with Plasmodium malariae should be considered if the paroxysms of fever occur every 72 hours and when the
parasitized erythrocytes demonstrate the characteristic band form trophozoite, neither
of which is consistent with this patient's clinical scenario.
Infection with Plasmodium ovale and Plasmodium vivax may show trophozoite and schizont forms on the peripheral blood smear with Schüffner
dots inside of enlarged erythrocytes, inconsistent with this patient's peripheral
blood smear findings.
Taylor SM, Molyneux ME, Simel DL, et al. Does this patient have malaria? JAMA. 2010;304(18):2048-2056. PMID: 21057136
This question was derived from MKSAP® 16, the Medical Knowledge Self-Assessment Program.