Introduction

Malaria is an infectious disease, characteristic feature of which is high fever. It is caused by a parasite, transmitted to humans through the bites of infected mosquitoes.  Malaria causes people feel very sick, with a high fever and shaking chills. Every year, approximately 210 million people are infected with malaria, and about 440,000 people die from the disease. Most of the people who die from the disease are young children in remote areas in Africa.

Malaria is most common in tropical and subtropical countries, unlike in temperamental climates. World health officials are trying to reduce the incidence of malaria by distributing bed nets to help protect people from mosquito bites as they sleep. Scientists around the world are working to develop a vaccine to prevent malaria.

International travel often costs taking preventive medicines before, during and after the trip. Many countries insist on these conditions. It depends upon the area of the journey and the chance of getting infected. Many malaria parasites are now resistant to the most common drugs used to treat the disease.

Signs & symptoms

Symptoms of malaria usually start about two weeks after the infected mosquito bite. Along with high fever, shaking chills, and sweating, they can include:

Nausea and vomiting

Headache

Diarrhoea

Tiredness or fatigue

Body pain

Jaundice

Kidney failure

Seizures/Convulsions

Confusion

Fainting

Blood in the faeces

Some people who have malaria experience cycles of malaria “attacks.” An attack usually starts with shivering and chills, followed by a high fever, followed by sweating and a return to normal temperature. Malaria signs and symptoms typically begin within a few weeks after being bitten by an infected mosquito. However, some types of malaria parasites can lie dormant in your body for up to a year.

Causes

Malaria is caused by plasmodium parasites, which are carried by anopheles’ mosquitos.

Only female mosquitoes spread the malarial parasites.

Mosquito transmission cycle

• Uninfected mosquito. A mosquito becomes infected by feeding on a person who has malaria.
• Transmission of parasite. If this mosquito bites you in the future, it can transmit malaria parasites to you.
• In the liver. Once the parasites enter your body, they travel to your liver — where some types can lie dormant for as long as a year.
• Into the bloodstream. When the parasites mature, they leave the liver and infect your red blood cells. This is when people typically develop malaria symptoms.
• On to the next person. If an uninfected mosquito bites you at this point in the cycle, it will become infected with your malaria parasites and can spread them to the other people it bites.

Other modes of transmission

Because the parasites that cause malaria affect red blood cells, people can also catch malaria from exposure to infected blood, including:

• From mother to unborn child
• Through blood transfusions
• By sharing needles used to inject drugs
• By organ transplant surgeries

Risk factors

The biggest risk factor for developing malaria is to live in or to visit areas where the disease is common. There are many different varieties of malaria parasites. The variety that causes the most serious complications is most commonly found in:

• African countries south of the Sahara Desert
• Some parts of Asia

Pathophysiology

Malaria, which predominantly occurs in tropical areas, is a potentially life-threatening parasitic disease caused by infection with Plasmodium protozoa transmitted by an infective female Anopheles mosquito vector. Individuals with malaria may present with fever and a wide range of symptoms.

Malarial merozoites in the peripheral blood. Note that several of the merozoites have penetrated the erythrocyte membrane and entered the cell.

The 5 Plasmodium species known to cause malaria in humans are P. falciparum, P. vivax, P. ovale, P. malariae, and P. knowlesi.Timely identification of the infecting species is extremely important, as P falciparum infection can be fatal and is often resistant to standard chloroquine treatment. P falciparum and P vivax are responsible for most new infections.

The Plasmodium species can usually be distinguished by morphology on a blood smear. P falciparum is distinguished from the rest of the plasmodia by its high level of parasitaemia and the banana shape of its gametocytes.

Among patients with malaria, 5-7% are infected with more than a single Plasmodium species. Co-infection with different Plasmodium species has also been described in the parasites’ mosquito vectors

Each Plasmodium species has a defined area of endemicity, although geographic overlap is common. At risk for contraction of malaria are persons living in or traveling to areas of Central America, South America, Hispaniola, sub-Saharan Africa, the Indian subcontinent, Southeast Asia, the Middle East, and Oceania. Among these regions, sub-Saharan Africa has the highest occurrence of P falciparum transmission to travellers from the United States.

Infection and reproduction

After a mosquito takes a blood meal, the malarial sporozoites enter hepatocytes (liver phase) within minutes and then emerge in the bloodstream after a few weeks. These merozoites rapidly enter erythrocytes, where they develop into trophozoites and then into schizonts over a period of days (during the erythrocytic phase of the life cycle). Rupture of infected erythrocytes containing the schizont results in fever and merozoite release. The merozoites enter new red cells, and the process is repeated, resulting in a quick increase in parasite burden.

This micrograph illustrates the trophozoite form, or immature-ring form, of the malarial parasite within peripheral erythrocytes. Red blood cells infected with trophozoites do not produce sequestrins and, therefore, are able to pass through the spleen.

A mature schizont within an erythrocyte. These red blood cells (RBCs) are sequestered in the spleen when malaria proteins, called sequestrins, on the RBC surface bind to endothelial cells within that organ. Sequestrins are only on the surfaces of erythrocytes that contain the schizont form of the parasite.

Residents of a malaria region may be exposed to the disease so frequently that they acquire a partial immunity, which can lessen the severity of malaria symptoms. However, this partial immunity can disappear if you move to a country where you’re no longer frequently exposed to the parasite.

Diagnosis

A blood test can show if you have malaria, but your doctor will also ask you about your medical history and any recent travel and do a physical exam. 

The blood test can tell your doctor:

• If the parasite is in your blood
• If certain medications will work against the parasite
• If your body has ever made antibodies to fight off malaria 

Treatments

The treatment will depend on things like:

• The type of parasite
• Severity of symptoms
• The geographic area of infection
• Age 
• Pregnant or not

Medications used in the treatment of malaria include:

Chloroquine or hydroxychloroquine. 

Artemisinin-based combination therapy (ACT). 

Atovaquone-proguanil, artemether-lumefantrine. 

Mefloquine.

Artesunate.

Some parasites that cause malaria have become resistant to almost all the medicines used to treat the illness.

Prognosis

Most patients with uncomplicated malaria respond well to treatment and show remarked improvement within 48 hours after the initiation of treatment. 

P falciparum infection carries a poor prognosis with a high mortality rate if untreated. However, if the infection is diagnosed early and treated appropriately, the prognosis is excellent.

Complications

Malaria is a serious illness that can be fatal if not diagnosed and treated quickly. Pregnant women, babies, young children and the elderly are particularly at risk.

The Plasmodium falciparum parasite causes the most severe malaria symptoms and most deaths.

As complications of severe malaria can occur within hours or days of the first symptoms, it’s important to seek urgent medical help as soon as possible.

Anaemia

P. falciparum causes vascular obstruction. When a red blood cell (RBC) becomes infected with P. falciparum, the organism produces proteinaceous knobs that bind to endothelial cells. The adherence of these infected RBCs causes them to clump together in the blood vessels in many areas of the body, causing microvascular damage and leading to much of the damage incurred by the parasite. The destruction of red blood cells by the malaria parasite can cause severe anaemia.

Cerebral malaria

In rare cases, malaria can affect the brain. Known as cerebral malaria, this will cause swelling in the brain, sometimes leading to permanent brain damage. It can also cause fits (seizures) or coma.

Other complications that can arise as a result of severe malaria include:

• liver failure and jaundice 
• shock
• pulmonary oedema 
• Acute Respiratory Distress syndrome (ARDS)
• Hypoglycaemia
• kidney failure
• swelling and rupturing of the spleen
• Dehydration

Serious complications are possible in pregnancy, such as:

• Premature birth – birth before 37 weeks of pregnancy
• low birth weight
• restricted growth of the baby in the womb
• stillbirth
• miscarriage
• death of the mother

Plasmodium falciparumcan cause cerebral malaria, pulmonary oedema, rapidly developing anaemia, and renal problems.

Disease & Ayurveda

        The most characteristic symptom of malaria is intermittent fever. An episode of high fever followed by a time period of normal temperature. This cycle continues known as the classic malaria paroxysm with bouts of illness alternating with symptom-free periods.

It has three successive stages.

1. cold stage for 15-to-60-minutes, characterized by shivering and a feeling of cold.
2. hot stage for 2-to-6-hours, with fever (sometimes reaching 41°C), flushed, dry skin, and often headache, nausea, and vomiting.
3.  sweating stage for (2-to-4 hours) during which the fever drops rapidly and the patient sweats. In all types of malaria, the periodic febrile response is caused by rupture of mature schizonts.

So, the Ayurvedic correlation is taken as Vishamajwara which means periodic fever.

Nidana

• Svabhavaja Hetu (internal factors) – the residue of the vitiated Dosha, after treatment of different diseases produce fever. Emaciated persons, person who is recently relieved from disease immediately indulging in unsuitable dietetics and life style etc. even the mildly vitiated Doshas, gain strength from Dooshya (Dhatu, Mala, Kala) and manifest Vishama Jvara (irregular or intermittent fever)
  • Agantuja Hetu(external factors)- extrinsic factors or Bhootabhishanga(microbial infections).The vitiation of the Doshas in the body occurs due to interference with environment.

 As the vishama Jvara is always Tridoshaja, the Sannipatika Jvara Nidana should be considered. They include:

• Irregularities in diet pattern,
• Fasting,
• Changes in food habit without following dietic regimen,
• Seasonal influences,
• Inhalation of substances with unpleasant smell,
• Intake of poisonous water and poisonous substances
• Habitation near mountains,
• Improper Panchakarma therapies,
• Improper adaptation of Ahara- Viharadi (diet and activities) after Shodana (eliminatory therapy) of the body,
• Abnormal labour, intake of unwholesome diet & regimen after delivery.
• Daysleep
• Janapadhodhwamsa Vyadhi(epidemic diseases) – The vitiation of the Jala (water), Desha(land) and kala(season) these may lead to the onset of VishamaJvara(irregular or intermittent fever). In malaria, polluted and stagnant water let the growth of mosquitoes and spresd of malarial parasite and disease outbreak.
• Krimi (parasites/ microorganism)
• Adharma (sinful actions) prevalent in the society, be it at the individual level or at the societal level, like improper eradication programmes of diseases, unhygienic & polluted water resources, absence of vaccination or preventive measures etc. can be held accountable for all the vyadhi especially Vishama Jvara/malarial fever.
• Different Manasika Hetus (causes for mental disorders) indicate that probably due to the mental stress accompanied by physical exhaustion as well as the lack of hygiene people.
• Ritu Vyapat (seasonal disorders) and other diseases which leads to decrease in the Vyadhikshamatva (immunity)of patient make the patient suffer from Vishama Jvara (irregular or intermittent fever).

Purvaaroopa

        Jwara – fever

            Swasan- difficulty in breathing

            Koojan – making buzzing sound

            Vaman – Vomiting

            Cheshtathe – abnormal body movements

            Vepathe – shivering

            Pralapathi – Delirium

            Ushna-seeta anga- irregular body temperature

            Hataprabha     – lack of vital energy

Visamjna – Fainting

Sakriddravam – diarrhoea

Samprapti

Due to causative factors, the vitiated doshas enter the rasa-rakta dhatus and cause fever along with decreasein agni. As in vishamajwara due to bhootabhishanga(microbes) krimi also should be considered as an important cause. While considering Krimi, Bahya and Abhyantara classification as well as the 4 types based on the Nidana of Krimi (aetiological factors for microbial infestation) are important.

The Samanya Lakshana (general features) of all Krimi include

Jwara – fever

 Vivarnata – discoloration

 Shoola – stomach pain

Bhrama – giddiness

Bhaktadvesha Aversion to food

Atisara – diarrhoea,

Chardi – vomiting,

and

 Swaasa – respiratory disorders

The Uthpathisthana(origin) of Raktaja Krimi is Raktavahi Dhamani and Sira. By this we can infer that the krimi relating to malarial infection may be a Raktaja Krimi. The Adrushta (invisible/micro) nature of Raktaja Krimi as well as the micro- nature of the plasmodium strain suggests that they belong to the Raktaja Krimi (blood born parasites) category. Acharyas have mentioned different types of Raktaja Krimi(blood born parasites). Raktaja krimi(blood born parasites) can also manifest Raktaja Vyadhi (disorders related to involvement of blood) out of which PleehaVridhi (splenomegaly) and YakrutVridhi (hepatomegaly) are among the presentations of malarial fever. Plihodhara (splenomegaly) presents with Mridu Jvara (mild fever) among its features, may well be malaria with same scenario in stages of vishamajvara (irregular or intermittent fever) where Rakta Dhatu is one among the Dhatu involved.

Lakshana

            Recurrent or intermittent fever, along with intervals of normal body temperature.

Divisions

1. Santata jwara
   1. Satata jwara
   1. Anyedyushkajwara
   1. Truteeyakajwara
   1. Chaturthakajwara

Prognosis

        Kricchrasadhya

            Asadhya if with complications like Delirium, difficulty in breathing, giddiness etc.

Chikithsa

        Treatment of Vishamajwara is mainly Langhana(lightening of body weight) therapies. Aama should be eliminated first and then agni should be enhanced. Then only nourishing therapies are advised. But the treatment should be done considering patient’s physical and mental strength.

Samana

Aamapachana

Agnideepana

Brumhana

Sodhana

In fever conditions, no sodhana therapies are advised.

Commonly used medicines

        Amruthotharam kashayam

            Dasamoolakaduthrayam kashayam

            Vyaghryadi kashayam

            Gorochanadi gulika

            Chukkumthippallyadi gulika

            Shadangam thoyam

Brands available

        AVS Kottakal

            AVP Coimbatore

            SNA oushadhasala

            Vaidyaratnam oushadhasala

Home remedies

There is no proven home remedy for malaria. Diagnosing early and proper medical treatment is always advised. But some preventive and immune-boosting measures may be helpful including intake of:

Citrus fruits

Cinnamon

Ginger

Grapefruit

Thulasi leaves (Holy Basil)

Diet

• To be avoided

Heavy meals and difficult to digest foods – cause indigestion.

Junk foods- cause disturbance in digestion and reduces the bioavailability of the medicine

Carbonated drinks – makes the stomach more acidic and disturbed digestion

Refrigerated and frozen foods – causes weak and sluggish digestion by weakening Agni (digestive fire)

Curd – causes vidaaha and thereby many other diseases

• To be added

Light meals and easily digestible foods

Green gram, soups, buttermilk boiled with turmeric, ginger and curry leaves

Freshly cooked and warm food processed with cumin seeds, ginger, black pepper, ajwain etc

Behaviour:

Take complete rest until completely recovered.

Once regaining normal health state, avoid sedentary lifestyle. Be active.

Avoid stress.

Protect yourself from very hot and cold climates.

Better to avoid exposure to excessive sunlight, wind, rain or dust.

Maintain a regular food and sleep schedule.

Avoid holding or forcing the urges like urine, faeces, cough, sneeze etc.

Yoga

In malaria and any other fever conditions, no exercises are recommended. Take complete rest until completely recovered.

After regaining normal health, stretching exercises and following a specific Yogacharya with yoga asanas like pavanamuktasana, vajrasana, etc are recommended for improving circulation and digestion.

Regular exercise helps improve bioavailability of the medicine and food ingested and leads to positive health.

 Yoga can maintain harmony within and with surroundings.

Pavanamuktasana

Vajrasana

All the exercises and physical exertions must be decided and done under the supervision of a medical expert only.

Research articles

http://iamj.in/posts/images/upload/2318_2325.pdf

https://www.ncbi.nlm.nih.gov/books/NBK8584/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3800859/