DIAGNOSIS.

malaria

Any child who presents with fever or unexplained systemic illness who has traveled or resided in
a malaria-endemic area within the previous year should be assumed to have life-threatening
malaria until proven otherwise. Malaria should be considered regardless of the use of
chemoprophylaxis. Important criteria that suggest P. falciparum malaria include symptoms
occurring <1 mo after return from an endemic area, intense parasitemia (>2%), ring forms with
double chromatin dots, and erythrocytes infected with more than 1 parasite.

The diagnosis of malaria is established by identification of organisms on Giemsa-stained smears

of peripheral blood (see Fig. 285-1 ). Giemsa stain is superior to Wright stain or Leishman stain.
Both thick and thin blood smears should be examined. The concentration of erythrocytes on a
thick smear is 2040 times that on a thin smear and is used to quickly scan large numbers of
erythrocytes. The thin smear allows for positive identification of the malaria species and
determination of the percentage of infected erythrocytes. The latter is useful in following the
response to therapy. Identification of the species is best made by an experienced microscopist
and checked against color plates of the various Plasmodium species (see Fig. 285-1 ). Although
P. falciparum is most likely to be identified from blood just after a febrile paroxysm, the timing
of the smears is less important than their being obtained several times a day over a period of 3
successive days. A single negative blood smear does not exclude malaria; it may be necessary to
repeat the smears as often as every 4-6 hours a day to confirm the diagnosis. Most symptomatic
patients with malaria will have detectable parasites on thick blood smears within 48 hr. For
nonimmune persons, symptoms typically occur 12 days before parasites are detectable on blood
smear. A monoclonal antibody test that is incorporated in a test strip for fingerprick blood
samples is as sensitive as a thick smear for detection of P. falciparum. Polymerase chain reaction
is even more sensitive but technically more complex.