Explanation : Clinical features of severe malaria include: impaired consciousness (including unarousable coma), prostration (i.e. generalized weakness so that the patient is unable to sit, stand or walk without assistance), multiple convulsions (more than 2 episodes within 24 hour period), deep breathing and respiratory distress (acidotic breathing), acute pulmonary edema and ARDS, circulatory collapse or shock, systolic blood pressure < 80 mm Hg in adults, acute kidney injury, clinical jaundice plus evidence of other vital organ dysfunction, and abnormal bleeding.

References:
https://apps.who.int/iris/bitstream/handle/10665/79317/9789241548526_eng.pdf

Explanation : Laboratory findings seen with severe malaria include: hyperparasitemia  ≥ 5% in non-immune traveler, all patients with parasitemia > 10%, hypoglycemia (< 40 mg/dl), metabolic acidosis (plasma bicarbonate < 15 mmol/l), severe normocytic anemia (Hemoglobin < 5 g/dL), hemoglobinuria, hyperlactatemia (lactate > 5 mmol/l), renal impairment (serum creatinine > 3 mg/dL or blood urea > 20 mmol/L), and plasma or serum bilirubin 3 mg/dL in conjunction with > 2.5% parasitemia

References :
https://doi.org/10.1111/tmi.12313_2
https://apps.who.int/iris/bitstream/handle/10665/79317/9789241548526_eng.pdf

Explanation : Parenteral artesunate is preferred for pregnant women with Plasmodium falciparum malaria.

References :
https://apps.who.int/iris/bitstream/handle/10665/79317/9789241548526_eng.pdf
https://www.cdc.gov/malaria/resources/pdf/Malaria_Managment_Algorithm_202208.pdf

Explanation : This is a feature of P. Falciparum where the trophozoites may look like they are on the surface of the RBC as opposed to within the cell.  This is much more common to see with falciparum than other types of malaria.

References :
https://www.cdc.gov/dpdx/resources/pdf/benchAids/malaria/Pfalciparum_benchaidV2.pdf
Trager W, Rudzinska MA, Bradbury PC. The fine structure of Plasmodium falciparum and its host erythrocytes in natural malarial infections in man. Bull World Health Organ. 1966;35(6):883-5. PMID: 5338378; PMCID: PMC2476278.

Explanation : In conscious patients, patients may present with anxiety, diaphoresis, dilated pupils, shortness of breath, cold sweats, tachycardia and light headedness.  If symptoms are protracted and severe, the patient may lose consciousness and develop generalized seizures and extensor posturing.  Because all of these clinical features can be present in severe malaria, hypoglycemia can be easily overlooked.  If hypoglycemia is present, WHO recommends giving 25 g of dextrose (preferably 10% dextrose) over a few minutes.  This should be followed by intravenous infusion with D5% or D10% at 200-500 mg/kg per hour with ongoing blood glucose monitoring.

References :
https://apps.who.int/iris/bitstream/handle/10665/79317/9789241548526_eng.pdf