Study common diseases (Differential diagnosis of malaria by clinical features)

[Dr.Habiib]

Differential diagnosis of malaria:

The goals of this topic:
1. To decrease the effect of this disease in our country.
2. To helps our doctors which may difficult to diagnosis as soon as possible.
3. Lack of laboratory investigation in our country makes to focus clinical symptoms carefully.
4. Many of our doctors work in rural city which may have any laboratory and sources of medical knowledge.
5. This step will give for young doctors to make stress in clinical pictures of any disease.

Clinical features of malaria:

1. Uncomplicated malaria symptoms:
Fever is the most common features of malaria, headache, joint pains, malaise, poor of appetite, body weakness and  cough , vomiting  or may be diarrhea.
 These symptoms are not specific for malaria only many other diseases have like these symptoms so you have to differentiate from these diseases.

What are diseases have these symptoms common in our country?
Influenza,  brucellosis, sand fly fever, acute respiratory infections, viral hemorrhagic fevers, tuberculosis, enteric fever, trypanosomiasis, visceral leishmaniasis, rickettsial fever, relapsing fever.

How can differentiate malaria case from these diseases depend on my clinical symptoms?

 The doctor to reach a good result you must find following:
1. Take full history from patient.
2. Search the specific symptoms of malaria:
 The malaria has specific clinical attack which are called (malaria paroxysm) including three stages:

A. Cold stage:

As the temperature begins to rise, there is intense headache and muscular discomfort. The patient feels cold, clutches blankets, and curls up shivering and uncommunicative. Within minutes the limbs begin to shake and teeth chatter, and the temperature climbs rapidly to a peak. The rigor usually lasts 10-30 minutes.
 
B. Hot stage:
By the end of rigor there is peripheral vasodilatation and the skin feels hot and dry. The temperature is high.

C. Sweating:
Profuse sweat then breaks out. It lasts for 2-4 hours. The patient is soaked in sweat and the temp falls. The patient feels exhausted and may sleep.

How can I differentiate different types of plasmodium malaria according paroxysmal malaria?
The untreated person which has fever for several days the doctor can differentiate types of plasmodium which causes malaria:
a. If malaria paroxysm attacks repeat every 48 hours the causative is plasmodium vivax, and plasmodium ovale , its name tertian malaria.
B. if malarial attacks are every 72 hours the causative is plasmodium malariae, its name quartan malaria.
C. if malaria paroxysm attack is every 36- 48hours or irregular the causative is plasmodium falciparum.


2. Complicated malaria (severe malaria):

The patient complicated malaria becomes behavioral changes, jaundice, severe anemia, extreme weakness and coma and shock.
NB. There are many other diseases have this symptoms including:
Coma: meningitis, encephalitis, typhoid fever, cerebrovascular accidents, trauma.
Jaundice: infectious hepatitis, leptospirosis, disease of the biliary tract.
Anemia: other types of haemolytic anemia like G6PD deficiency.

How can differentiate malaria from these diseases?
Again the golden role is to take a full history from patient, don`t for get to seek malaria typical signs (paroxysm malaria) and important to make microscopic examination and other useful investigation because these complication are very serious.

[Diagnostic]

I would like to attach malaria Somalia map to the topic due to it's importance..

According to Interzonal malariogenic strata, the Somalia is divided into 3 zones:
ZONE 1: Awdal, W. Galbeed, Togdheer, Sanaag, Sool, Bari, Nugaal, Mudug & Galgaduug
ZONE 2: Gedo, Bay, Bakool & Hiraan
ZONE 3: Middle & Lower Shabelle, Middle Juba & Lower Juba

Malaria is Hypoendemic in ZONE1, Mesoendemic in ZONE 2 & Hyperendemic in ZONE 3.

This information about malaria distribution inside Somalia is very important when you diagnose a case with fever, headache, vomiting & joint pain.
For example, if you are in ZONE 1 like Galkayo, and a patient come with the above symptoms and he has no history of travel to ZONE 3, you better move malaria to the bottom of your differential diagnosis.

The following Map will be helpful:
Click here to download the Map

[Admin]

Strong points from history:

Fever: is often irregular and may not be detected at time of physical examination.
Chills: Often periodic. Rigors not uncommon
Sweats: Often periodic. Commonly profuse and nocturnal
Headache: Usual at presentation
Malaise: Usual at presentation
Arthralgias: Common, and usually generalized
Body aches: Common
Nausea: Common
Vomiting: Common, may affect ability to take oral medication
Diarrhea: Uncommon, but not useful in ruling out the diagnosis of malaria
Cough: May be an early symptom in children, but is uncommon in adults

Strong points from physical examination:

General appearance: Severe disease can result in prostration. In a child, prostration is the inability to sit unassisted although normally able to do so, or to feed in the case of a child too young to sit. In adults, prostration usually manifests as extreme weakness

Vital signs: for hypotension

Skin exam: for abnormal bleeding, jaundice, or pallor Skin, mucosal, and other forms of bleeding may be indicative of disseminated intravascular coagulation, which is uncommon in adults and rare in children. Jaundice is common in adults, uncommon in children. Extreme pallor may be a sign of severe anemia, and laboratory evaluation may confirm hemoglobin <5 g/dL or hematocrit <15%. Rash is uncommon

Chest exam: for signs of respiratory distress, Respiratory distress may be shown by sustained nasal flaring, intercostal recession, deep (acidotic, Kussmaul's) breathing. Pulmonary edema may occur and in some cases only be apparent radiographically. Common in adults, rare in children

Abdominal exam: for splenomegaly Although splenomegaly is a feature of malaria, lymphadenopathy is uncommon. In addition, dark red or black urine representing hemoglobinuria may be seen as part of the physical exam. Laboratory evaluation will confirm the absence of microscopic hematuria

Neurologic exam: for coma or convulsions Coma can be assessed using the Glasgow (adults) or Blantyre (children) coma scales. Coma is defined as Glasgow score <9 or Blantyre score 2. Seizures may be a consequence of parasite sequestration in the brain, hypoglycemia, or fever in children and may be generalized or focal.
Follwing the steps below we can also exclude or prioritize our list of diffirential diagnosis given above by dr.habiib:

Influenza:
1- Runny nose and sore throat are uncommon in malaria.

Brucellosis:
1- History of animal exposure
2- Longer incubation period
3- Drenching sweats that recur in late afternoon or evening

Acute respiratory infections:
1- Cough is uncommon in adults but may be an early sign in children.
2- Chest pain is uncommon
3- Can be ecluded with physical exam by listening to chest.

Viral hemorrhagic fevers (Dengue):
1- An incubation period of 4-7 days is not typical of malaria.
2- Malaria also is not associated with severe myalgias, rash, lymphadenopathy, conjunctivitis, or pharyngeal erythema.
3- Pulse usually rises with fever in malaria.

Tuberculosis:
1- Chronic cough is uncommoin in malaria
2- Fever is high in malaria

Enteric fever:
1- Abdominal pain and constipation are uncommon in malaria.
2- Rashes are not associated with malaria.
3- Pulse usually rises with fever in malaria.

Trypanosomiasis:
1- Chancres, rash, and lymphadenopathy are not associated with malaria.

Visceral leishmaniasis: (Must be acute)
1- Allergic phenomenon, rash, lymphadenopathy, and eosinophilia are not characteristic of malaria.

Rickettsial fever:
1- Lymph node abnormalities and eschars are not associated with malaria.

Sepsis:
1- Bacteremia and sepsis can mimic and accompany severe malaria.

Yellow fever:
1- Conjunctival signs are not associated with malaria.
Written with the help of PIER (Physicians' Information and Education Resource)
Dr.Mahdi

[Waxbaro!]

Although malaria cannot be diagnosed clinically with accuracy & thick and thin blood smears are the mainstay of diagnosis but you presented a nice step-by-step diagnostic approach.

Thanks for the article & I am sure everyone will get benefit from it.