Incidence in Europe and North America: 2.36/100,000 population/year. Mortality in Africa and Asia: 7.5 to > 80/100,000/year. The infectious agent is generally Plasmodium falciparum in Africa, while P. vivax, ovale, malariae and knowlesi are more common in Asia and other endemic regions.

The vector is the infected female Anopheles mosquito. Sporozoites are inoculated during a bite  by the their saliva, containing sporozoites, into the bloodstream. Within a few hours, the sporozoites move to the liver, enter hepatocytes, and begin to divide. The sporozoites eventually form mature tissue schizonts containing merozoites (extra-erythrocytic schizogony) within 7-10 days. The schizonts rupture and release thousands of merozoites, which enter the bloodstream and invade red blood cells. These merozoites continue to reproduce in the red blood cells (erythrocytic schizogony), but some transform into male or female gametocytes. These merozoites and gametocytes burst the red blood cells that house them, resulting in hemolysis and a further release of merozoites into the bloodstream. These cycles of red cell infection last around 48 hours. The gametocytes present in the bloodstream are ingested by the Anopheles during another bite, and the rest of the parasite's cycle takes place inside the insect (see table).

The incubation period varies from 5 days to 4 weeks. The clinical manifestations of the disease are caused by hemolysis attacks: fever attacks (chills lasting 1-2 h, followed by major hyperthermia lasting 3-4 h and then profuse sweating for 2-4 h) that recur every 48 to 72 h, and organ hypoperfusion as the shizonts adhere to the walls of small vessels and capillaries. During their maturation cycle, P.vivax and ovale can pass through a so-called hypnozoite stage, which allows the parasite to remain quiescent in the liver for a long period before resuming active infection.

The clinical manifestations of malaria vary in severity, from almost asymptomatic (headaches) to very severe forms: anemia, thrombocytopenia, coagulopathy (sometimes leading to disseminated intravascular coagulation), shock, respiratory failure, neurological damage (neuromalaria), hypoglycemia, acute renal failure.

Anesthetic implications: 

-         keep that diagnosis in mind: endemic areas, migrants or returning from travel (see world map). Post-operative recurrences may occur after a long period of asymptomatic disease (especially P vivax and P ovale).

-         aspecific symptoms

-         a negative blood test does not exclude the diagnosis

-         in the event of a positive thick blood smear without signs of malaria: treat and postpone the operation for one week.

-         in the event of anesthesia during an crisis: monitor blood sugar levels (risk of hypoglycemia), avoid hypoventilation (risk of intracranial hypertension in the event of cerebral involvement) and volume overload (ventricular dysfunction), and monitor platelets, hemoglobin and renal function (risk of tubular necrosis, hyponatremia and hyperkalemia).

-         in the event of a crisis of fever during anesthesia: differential diagnosis with malignant hyperthermia

-         treatment of severe crisis: follow the advice of an infectiologist. 

Otherwise, very slow IV or IM artesunate:         3 mg/kg/dose if < 20 kg 

                                                                            2.4 mg/kg/dose if > 20kg

                       1 dose 12 and 24 h after 1st dose, then 1 dose/d max. 7 days

                       relay with artemisinin p os, as soon as possible

                       risk of hemolysis 2-3 weeks later in case of hyperparasitemia or young age

The WHO recommends combining artesunate with one of the following antimalarial drugs: mefloquine; pyronaridine; sulfadoxine-pyrimethamine; artemether-lumefantrine; dihydroartemisinin-piperaquine. Cases of partial artemisinin resistance have been described in the Mekong area, Eritrea, Uganda and Rwanda.

References : 

-        Zanfini BA, Dell'Anna AM, Catarci S, Frassanito L, Vagnoni S, Draisci G.
Anesthetic management of urgent cesarean delivery in a parturient with acute malaria infection.
Korean J Anesthesiol 2016 ; 69 : 193-6

-        Soltanifar D, Carvalho B, Sultan P.
Perioperative considerations of the patient with malaria.
Can J Anesth 2015 ; 62:304–18

-        Shafya SZ, Hakima M, Henga R, Tobias JD.
Anesthetic implications of malarial infection in a child.
J Med Cases 2019;10: 84-8

-        Espina-Bertoso S.
Malaria for the anaesthetist.Tutorial 176.
Update in Anaesthesia, Sept 2010, p 24-7.

Updated: January 2024