Fever in a returning traveller: malaria until proven otherwise

If you take one habit from this diploma into your consulting room, make it this: fever in anyone who has been in a malaria-endemic area is malaria until a competent laboratory says otherwise. Falciparum malaria can kill within days, most cases present within a month of return, and the early picture is deliberately unhelpful — fever, headache, myalgia, sometimes diarrhoea or cough. There is no clinical pattern reliable enough to rule it out.

The examiners know this, which is why the reflex is worth marks across every paper. In a data question, the marks usually sit in the sequence, not the diagnosis:

• Ask where, when, and what prophylaxis (taken imperfectly, as it usually is).
• Test — thick and thin films, or a rapid diagnostic test, urgently. Thick films find the parasite; thin films speciate it and give the parasitaemia.
• Repeat — a single negative film does not exclude malaria. UK guidance is to examine films daily for three days before calling it off.
• Assess severity — impaired consciousness, acidosis, hypoglycaemia, high parasitaemia — because severity, not species alone, drives management.

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