Biology Reference
In-Depth Information
3. SYMPTOMS AND SIGNS OF VIVAX MALARIA
3.1. Fever
Infection of a non-immune host results in a prodromal period followed by an
acute fever. Prodromal symptoms can include increasing headache, anorexia,
malaise, myalgias and/or gastrointestinal symptoms for one or more days,
sometimes with periodicity (
Kitchen, 1949b
). A low-grade prodromal fever
without paroxysmal symptoms (below) may also occur. Kitchen describes
the prodromal phase being followed by a remittent fever (continuous fever
with daily exacerbations) and then an intermittent daily fever (
Kitchen,
1949b
). Observations in non-immune hosts indicate that 'tertian fever' is
frequently a misnomer, with Kitchen reporting that 'it should be empha-
sised…that the intermittency so developed is invariably quotidian' (once
daily) rather than tertian (every second day) because 'the great majority of
the vivax plasmodia are segregated into two pyrogenic broods' with shizog-
ony occurring approximately 24 h apart (
Kitchen, 1949b
). With the Mada-
gascar strain, intermittent fevers were also more frequently quotidian than
tertian (
James, 1926
), but each pattern was seen equally frequently with the
Chesson strain (
Coatney et al., 1971
).
Tertian fevers have been reported in vivax-endemic areas since ancient
times, with first descriptions attributed to Hippocrates (
Adams, 1849
); these
are more likely in those with some pre-existing exposure and immunity
(
Kitchen, 1949b
), but even with past infection with heterologous strains,
quotidian fever can occur more frequently than a tertian pattern (
Kitchen,
1949b
).
The 'paroxysm' has long been recognised as the periodic febrile
response to
Plasmodium
infection and was shown by Golgi in the 1880s to
occur following rupture of schizont-infected red cells (
Golgi, 1886
,
1889
).
The paroxysm is classically, but not invariably, preceded by a 'cold stage' of
chills and a rigor (
Kitchen, 1949a
). A chilly sensation proceeds to shiver-
ing and then intense muscle tremors, chattering of teeth and sometimes
violent shaking. When present, Kitchen observed the duration of the rigor
to last from 5 to over 90 min; the mean duration was 50-55 min (
Kitchen,
1949a
). The temperature rises before the rigor ceases, usually reaching a
peak 1-3 h after the rigor finishes, commonly 39.5-40.5 °C but occa-
sionally over 41.5 °C (
Kitchen, 1949b
). Defervescence is accompanied by
sweating and fatigue. Primary infection in adults results in fevers continu-
ing for a minimum of 3-4 weeks (reviewed by
Kitchen (1949a)
and in
Chapter 5).
