It may be asymptomatic, mild illness (uncomplicated malaria) or severe illness (severe malaria)}Intermittent fever is the most characteristic symptom of malaria. Three classical stages can be distinguished in a typical attack of malaria: –– The cold stage: the patient feels cold and shivers –– The hot stage: the patient feels hot –– The sweating stage: associated with sweating and relief of symptoms}A complete physical examination has to be performed in any patient presenting with fever or history of feve}When people are frequently exposed to malaria, they develop partial immunity. In such people, the classical stages of a malaria attack above may not be observed}Also, in people who have had partial treatment with antimalarial medicines, these classical stages may not be pronounced}<b>Uncomplicated Malaria</b><br> Common symptoms/signs of uncomplicated malaria yy Fever: above 37.5°C (taken from the axilla ) or history of fever yy Loss of appetite, mild vomiting, diarrhoea yy Weakness, headache, joint and muscle pain yy Mild anaemia (mild pallor of palms and mucous membranes); occurs commonly in children yy Mild dehydration (dry mouth, coated tongue, and sunken eyes). In adults, sunken eyes are usually a sign of severe dehydration yy Enlarged spleen (in acute malaria it may be minimally enlarged, soft and mildly tender)}<b>Complicated/Severe Malaria</b><br>It is an immediate threat to life and is therefore a medical emergency. Malaria is regarded as severe if there are asexual forms of P. falciparum in blood plus one or more of the following complications below.<br><b>Cerebral malaria</b>Deep coma (unable to localise a painful stimulus), Normal CSF, parasitaemia<br><b>Severe anaemia: </b>Hb <5g/dl with parasitaemia (<7 g/dl in pregnancy)<br><b>Respiratory distress</b> Tachypnoea, nasal flaring and intercostal recession in a patient with parasitaemia<br><b>Hypoglycaemia</b>Blood glucose <40 mg/dl (2.2 mmol/L) with parasitaemia<br><b>Circulatory collapse</b>Clinical shock (systolic pressure <50 mmHg for children and <80mmHg for adults, with cold peripheries, clammy skin) with parasitaemia<br><b>Renal failure</b>Urine output < 12 ml/kg in 24 hours and plasma creatinine > 3.0 mg/dl, with parasitaemia<br><b>Spontaneous bleeding</b>Parasitaemia with unexplained spontaneous bleeding (haematemesis, melaena, or prolonged bleeding from nose, gum or venipuncture site<br><b>Repeated convulsions</b>2 or more convulsions in 24 hours, with parasitaemia<br><b>Acidosis</b>Deep (acidotic) breathing and plasma bicarbonate <15 mmol/L, with parasitaemia<br><b>Haemoglobinuria</b><br>Parasitaemia, haemoglobin in urine (dark coloured urine but no RBC’s)<br><b>Pulmonary Oedema</b>Deep breathing, fast breathing, laboured breathing (nasal flaring, intercostal recession and chest indrawing), Cheyne stokes breathing<br><b>Impaired consciousness</b>Parasitaemia with depressed level of consciousness but can localize a painful stimulus, or change of behavior, confusion, drowsiness<b>Jaundice</b>Parasitaemia with unexplained jaundice<br><b>Prostration</b>Unable to sit, in a child normally able to do so or unable to drink in one too young to sit<br><b>Severe vomiting</b>Vomiting everything, not able to drink or breastfeed<br><b>Severe dehydration: </b>Sunken eyes, coated tongue, lethargy, inability to drink<br><b>Hyperpyrexia</b>: Temperature >39.50 C, with parasitaemia<br><b>Hyperparasitaemia</b>: Parasite count > 250,000 /μl, > 10%<br><b>Threatening abortion</b>Uterine contractions and vaginal bleeding