Pediatric Malaria Workup: Approach Considerations, Other Tests, Blood Smear Examination 21/11/21 20.

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Pediatric Malaria Workup

Updated: Jun 03, 2020
Author: Parang N Mehta, MD; Chief Editor: Russell W Steele, MD more...

WORKUP

Approach Considerations
Demonstration of the parasite in a smear of the blood definitely establishes the presence of
malaria. A negative finding on examination does not rule out malaria. Only 50% of children with
malaria have positive smear findings, even on repeated examination.

Asymptomatic parasitemia is common in children from an endemic area who have partial
immunity to the disease. A positive smear for malaria parasite does not always confirm a
diagnosis of malaria in these children. More importantly, a positive smear should not stop the
diagnostic effort in a febrile illness.

Lumbar puncture is indicated to rule out meningitis in cerebral malaria and febrile seizures with
malaria. Severe P falciparum malaria is often associated with hypoglycemia. Lower blood
glucose levels are associated with higher mortality rates.

Other Tests
Serologic tests provide confirmation of past malaria in patients and are valuable for
epidemiologic studies. These tests are also useful for screening donated blood and diagnosing
hyperactive malarial splenomegaly. Among the tests used are:

Indirect fluorescent antibody test (IFAT)

Indirect hemagglutination antibody (IHA) test

Enzyme-linked immunosorbent assay (ELISA)

Immuno-chromatographic test (ICT) for filariasis

All of these tests produce positive results several days after malarial parasites appear in the
blood and so do not help in the diagnosis of the acute infection for treatment purposes.

Dipstick tests based on the detection of P falciparum histidine-rich protein-2 (PfHRP-2) antigen
are specific for P falciparum infections and do not detect the other 3 species. Dipstick tests
based on the detection of parasite lactate dehydrogenase are now available; these tests can
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Pediatric Malaria Workup: Approach Considerations, Other Tests, Blood Smear Examination 21/11/21 20.11

detect P falciparum and P vivax. These tests have high sensitivity and specificity, require no
special equipment or training, and produce results rapidly. They offer an advantage where the
disease is uncommon and blood smear examination expertise is not readily available. However,
they remain positive for a week or more after the treatment and cure and, in this situation, can
yield false-positive results.

Deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) probes and polymerase chain reaction
(PCR) assays have good sensitivity and specificity but require sophisticated expensive
equipment.

Blood Smear Examination

Both thick and thin films are essential. If the parasitemia is light, a thin film examination may
miss the diagnosis. Thick films save time in diagnosis of scanty infections but make species
identification of the parasite difficult. At least 100-200 fields of a thick film should be scrutinized
before a slide is reported as negative for malaria. In doubtful cases, the examination can be
repeated after 4 hours.

Obtaining thick and thin blood films at the bedside is important. These films may have to be
taken repeatedly for diagnosis. Earlobe or finger prick is used for older children; the great toe is
used in infants.

Take a large drop of blood on one end of a clean slide, spread uniformly, and air-dry. A smaller
drop should be spread thinly so that the end of the smear does not reach the end of the slide.
Giemsa staining is suitable for identifying malarial parasites in these films.

Various techniques to enhance the diagnostic value of the peripheral blood smear examination
are in use. Fluorescent staining and microscopy, centrifugation, selective magnetic separation
techniques, and other techniques have been used but have only a moderate effect.

Histologic findings

The appearance of the parasite varies in the thick and thin films. The thick unfixed film shows
only leucocytes and parasites; erythrocytes are destroyed in the staining process. The parasites
themselves are also altered.

Young trophozoites appear as incomplete rings or spots of blue cytoplasm with discrete red
nuclei. In mature trophozoites, the cytoplasm may be fragmented, and the various
characteristics of the different species are often indistinct.

Gametocytes and schizonts usually retain their characteristic appearances. Thin film
examination is essential for the accurate identification of plasmodial species, which has an
important bearing on treatment.

Treatment & Management

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