Malaria is one of the most devastating parasitic diseases, affecting a population in excess of 500 million and causing between 700,000 and 2.7 million deaths a year world-

wide. ' ' In the year 2000, approximately 27 million U.S. travelers visited countries where malaria is endemic. In 2002, the Centers for Disease Control and Prevention indicated that there were 1,337 cases of malaria, of which 849 were in U.S. civilians, 33 in U.S. military personnel, and the rest in foreign civilians.5 There were eight fatalities, all due to Plasmodium falciparum. The primary reasons for morbidity and death in malaria are failure to take recommended chemoprophylaxis, inappropriate chemoprophylaxis, delay in seeking medical care or in initiating therapy promptly, and misdiagnosis. Evaluation of a patient should include specific travel history, details of chemoprophylaxis, and physical findings (e.g., splenomegaly).

Malaria is transmitted by the bites of the Anopheles mosquitoes which introduce into the bloodstream one of four species of sporozoites of the plasmodia (Plasmodium falciparum, P. ovale, P. vivax, or P. malariae).47-56 Initial symptoms of malaria are nonspecific and may resemble influenza and include: chills, headache, fatigue, muscle pain, rigors, and nausea. The onset of the symptoms is between 1 and 3 weeks following exposure. Fever may appear 2 to 3 days after initial symptoms and may follow a pattern and occur every 2 or 3 days (P vivax, P. ovale, and P malariae). Fever with P falciparum can be erratic and may not follow specific patterns. It is not unusual for patients to have concomitant infections with P vivax and P falciparum. Fal-ciparum malaria must always be regarded as a life-threatening medical emergency.

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