INFECTIONS - Medicine for Mountaineering and Other Wilderness Activities - page 318

al chills and fever appear. Shivering, chattering teeth, cold and clammy skin, and a feeling
ofchillinessthatisnotrelievedbyheatingpadsorblanketscharacterizethisstage.Anhour
later, the febrile stage begins with a flushed face, a feeling of intense heat, headache, often
delirium, and temperature as high as 107°F (41.5°C). This stage lasts about two hours and
is followed by drenching sweats and a fall in temperature. Headache, backache, and mus-
cular aches may be very severe.
The repeated occurrence offebrile episodes at regular intervals suchasevery day,every
other day, every three days—occasionally at irregular intervals—is characteristic of mal-
aria. In severe cases vomiting, diarrhea, severe anemia, dark urine containing elements of
destroyed red blood cells, shock, and coma may occur. Enlargement of the liver or spleen
may be present.
Treatmentconsistsofgeneralsupportivemeasuresandspecificdrugtherapy.Restinbed
and maintenance of body warmth during the chill is highly desirable. Since water losses
by sweating may be severe, a large fluid intake should be encouraged. Fluids and salt lost
by vomiting or diarrhea also must be replaced. A careful record of temperature and pulse
shouldbekept.Ifpossible,bloodsmearsshouldbemadeduringthechillforlateridentific-
ationoftheparasites.Duringanacuteepisodeofmalaria,thesubsequentperiodoftherapy,
and for two weeks following recovery, strenuous exercise should be avoided to prevent
rupture of the spleen.
Specific treatment for malaria should be given by a physician familiar with its various
types and manifestations. The most effective general regimen for chloroquine-sensitive
malaria consists of chloroquine and primaquine.
Plasmodium falciparum malaria is the most dangerous form of malaria for two reasons:
It produces the most severe disease, and strains resistant to chloroquine have been found
throughout the world except for isolated pockets in Central and South America. Exped-
itions into areas where malaria is present should consider carrying mefloquine, quinine,
pyrimethamine, and doxycycline to treat chloroquine-resistant falciparum malaria. Instruc-
tion by a physician should be obtained before using these drugs.
Before leaving for a region in which malaria is present, a traveler's clinic or the Centers
forDiseaseControlandPreventionshouldbeconsultedtodetermine whetherchloroquine-
resistant falciparum malaria has been found in that area. Chloroquine prophylaxis effect-
ively prevents malaria caused by strains that are not resistant. Treatment should start two
weeks before entering an endemic area and continue for five weeks after leaving. Any ill-
nessoccurringwithinfiveweeksafterleavingamalarial areashouldbereportedtoaphys-
ician.
If travel is anticipated into areas where chloroquine-resistant malaria is present, meflo-
quine(Lariam®)shouldbetakenbeginningoneweekbeforetravelandcontinuingforfour
weeksafterreturn;contraindicationsincludepregnancy,psychiatricillness,andseizures.A
combination of atovaquone and proguanil (Malarone®) is an alternative antimalarial agent