618 Malaria 



phase. A marked anemia may occur within a few days, especially in 

 malignant tertian in which the parasitemia has reached 925,999/mm3 in 

 extreme cases (109). There is sometimes a temporary increase in leuco- 

 cytes during a paroxysm but such an increase, if it occurs at all, is fol- 

 lowed by a reduction. After some days in an uncomplicated infection 

 there is usually a leucopenia (3,500-4,500 leucocytes/mm^, or sometimes 

 less). The accumulation of pigment in leucocytes, mostly the large mono- 

 nuclears, is characteristic. Ingested pigment is to be expected also in the 

 lymphoid-macrophage cells in the viscera. 



Enlargement of the spleen is another characteristic effect, so much so 

 that the "splenic index" has been used to advantage in malaria surveys. 

 Enlargement of the spleen in vivax malaria usually is not evident in 

 white adults until after a week or so of the patent period (110), but the 

 splenic response is more rapid in infants and young children. Spleno- 

 megaly is much less noticeable in quartan than in tertian malaria, usually 

 develops rather slowly in whites, and may be absent in negro patients. 

 Jaundice is fairly common and may be marked in some malignant tertian 

 cases. The condition may be expected in acute vivax malaria with a red 

 cell count dropping below 2,000,000 during the first week or ten days, 

 but is seen less frequently in slowly developing cases. 



In contrast to the other types, falciparum malaria may be considered 

 potentially lethal, although some patients seem tolerant to fairly heavy 

 infections and may show comparatively mild attacks. In the simpler 

 falciparum cases, no particular organ system is extensively involved. 

 Even without localization, however, the parasites may multiply rapidly 

 enough to overwhelm the patient unless the infection is checked. 



Localized, or pernicious, malignant tertian occurs primarily in the 

 tropics and in areas where the disease is highly endemic. Pernicious cases 

 are generally severe and their development is favored by malnutrition, 

 fatigue, heat prostration, drug addiction, and the like. The cerebral 

 varieties involve localization in the nervous system. Effects include delir- 

 ium, convulsions, failure of muscular coordination, amnesia, difficulties 

 in speech, partial paralysis, indications of meningitis, or simulation of 

 acute intoxication. The clumping of invaded corpuscles may lead to 

 thrombus formation in cerebral capillaries, sometimes with resulting coma 

 or death. The visceral (or algid) types of pernicious malaria involve 

 localization in the digestive and circulatory systems primarily. The sur- 

 face of the body feels cold. Symptoms may suggest acute appendicitis, 

 bacterial dysentery, cholera, gastritis, peritonitis, or typhoid fever. Cir- 

 culatory involvement often leads to angina-like pains and symptoms of 

 thrombosis, with indications of heart failure. However, fatal cases may be 

 the result of vascular collapse more often than of cardiac failure (67). 

 The adrenal glands may be invaded, sometimes with degenerative changes 



