Categories: Health

Identification and management of co-infections in people with malaria

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What you need to know

Co-infections with malaria affect up to half of children in endemic countries and around one in seven travellers with malaria
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A positive diagnostic test does not mean malaria is the only, or even a contributing, cause of current illness
In settings where resources are constrained, limited diagnostic capacity can influence the diagnosis of co-infections, so vigilance is required for clinical features atypical for malaria
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A 16 year old Ugandan girl is brought to the emergency department with a three day history of fever, headache, cough, and myalgia. She has had several episodes of malaria in the past. On admission, she is febrile, tachycardic, tachypnoeic, and has oxygen saturations of 90% in air. A malaria rapid antigen test is positive for Plasmodium falciparum and a chest radiograph shows left sided pneumonia. She is admitted and treated with antimalarials, antibiotics, and oxygen. She makes a full recovery over five days. At discharge, the cause of the pneumonia and the contribution of malaria to the illness remain unresolved.

Introduction

Malaria is the symptomatic illness caused by the mosquito transmitted parasites Plasmodium falciparum, P vivax, P ovale, P malariae, and P knowlesi. It is one of the most common causes of fever in many malaria endemic countries and in travellers returning from those countries.1 The World Health Organization estimated 249 million malaria cases in 2022 worldwide, 94% attributable to P falciparum infections in Africa, where children have the greatest burden of severe disease.2

In patients who have evidence of acute or recent malaria infection, co-infections with other pathogens occur commonly.3 In this article, we consider the challenges of diagnosing bacterial, viral, and parasitic co-infection in patients who have malaria, and the related challenge of attributing illness to malaria in endemic countries. We focus on how to assess …

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