DIAGNOSIS AND MANAGEMENT OF MALARIA

DIAGNOSIS AND MANAGEMENT OF MALARIADr. Nisheeth M. Patel3rd Year ResidentM. D. Medicine

Introduction: Protozoal disease:Plasmodium species:P. vivax P. falciparumP. ovaleP. malariaeTransmitted by infected female anopheles mosquito

Life cycle:

Diagnosis:Demonstration of asexual forms of parasite in stained peripheral blood smearMicroscopy:Thick blood smearThin blood smearRDT (Rapid Diagnostic Test)PfHRP2 dip stick Plasmodia LDH dip stick

Thick blood smearUneven in thicknessFor plasmodia identificationAsexual parasite per 200 WBCsSensitive, inexpensiveRequires experienceUnderestimate true count

Thin blood smearSpecies identification and quantificationRBCs containing asexual parasite per 1000 RBCsSevere Malaria, assess stage of parasite developmentCount PMNs containing malarial pigmentRapid inexpensive prognostic infoInsensitive

PfHRP2 dip stickRapid, relatively inexpensiveSensitive Only for P. FalciDo not quantitate+ve after several weeks of infectionPlasmodia LDH dip stickOne band in genus specific, other for P. falciRapid sensitiveMiss low level p. vivax, ovale or malariaeDo not quantitate

A negative blood smear makes the diagnosis of malaria unlikely. if first smear is negative and high suspicion of malariaRepeat PSMP should be performed every 12-24h for 2 days, if malaria is strongly suspected.If all 3 are negative, the diagnosis of malaria has been essentially ruled out.

Treatment:The aims of the Malaria case management are:To provide prompt and complete treatment to all suspected/ confirmed cases of malariaTo prevent progression of mild cases of malaria in to severe or complicated from of malariaTo prevent deaths from severe and complicated malariaTo prevent transmission of malariaTo minimize risk of spread of drug resistant parasites by use of effective drugs in appropriate dosage by everyone.

Uncomplicated P. Vivax malariaUncomplicated malaria is defined as symptomatic malaria without signs of severity or evidence (clinical/ laboratory)of vital organ dysfunction.Dosage of CQ (CQ sensitive)25 mg/kg (base) divided over 3 days.Day 1 -10mg/kg Day 2- 10 mg/kgDay 3- 5 mg/kgPlus Primaquine 0.25 mg/kg for 14 days along with food after negative G6PD testing

In mild to moderate G6PD deficiency, primaquine to be given 0.75 mg/kg once a week for 8 weeksIn severe deficiency, it should not be givenAlso contraindicated in pregnancy and children 30 minprostration, i.e. generalized weakness so that the patient is unable walk or sit up without assistance failure to feedmultiple convulsions more than two episodes in 24 h or activity of subtle convulsion

Cont.deep breathing, respiratory distress (acidotic breathing)circulatory collapse or shock, systolic blood pressure < 70 mm Hg in adults and < 50 mm Hg in childrenclinical jaundiceAnuria haemoglobinuriaabnormal spontaneous bleedingpulmonary oedema (radiological)

Laboratory findings:hypoglycaemia (blood glucose < 2.2 mmol/l or < 40 mg/dl)metabolic acidosis ( pH < 7.25 or plasma bicarbonate < 15 mmol/l)severe normocytic anaemia (Hb < 5 g/dl, packed cell volume < 15%)haemoglobinuriahyperparasitaemia (> 2%/100 000/l in low intensity transmission areas or > 5% or 250 000/l in areas of high stable malaria transmission intensity)hyperlactataemia (lactate > 5 mmol/l)renal impairment (serum creatinine > 3 mg/dL).

Decreased platelet count (3 s) Prolonged partial thromboplastin time Decreased fibrinogen (4mmol/L(100mg/dL)maintain with glucose containing infusion.Severe anaemia:Hct level should be measured every 6-12h Hct falls