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Transcript of malaria presentation
![Page 1: malaria presentation](https://reader035.fdocuments.us/reader035/viewer/2022081504/55cf915f550346f57b8cfa22/html5/thumbnails/1.jpg)
Malaria - Update
Dr.Girish Vaswani (D.N.B. med)
Consulting Physician
Bhatia hospital
Motiben Dalvi
Kothari Hospital
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Plasmodium species which infect humans
Plasmodium vivax ( B. tertian)
Plasmodium ovale ( B. tertian)
Plasmodium falciparum ( M.tertian)
Plasmodium malariae (quartian)
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Exo-erythrocytic (hepatic) cycle
Sporozoites
Mosquito Salivary Gland
Malaria Life CycleLife Cycle
Gametocytes
Oocyst
Erythrocytic Cycle
Zygote
Schizogony
Sporogony
Hypnozoites(for P. vivax and P. ovale)
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Malaria Transmission Cycle
Parasite undergoes sexual reproduction in the mosquito
Some merozoites differentiate into male or female gametocyctes
Erythrocytic Cycle: Merozoites infect red blood cells to form schizonts
Dormant liver stages (hypnozoites) of P. vivax and P. ovale
Exo-erythrocytic (hepatic) Cycle: Sporozoites infect liver cells and develop into schizonts, which release merozoites into the blood
MOSQUITO HUMAN
Sporozoires injected into human host during blood meal
Parasites mature in mosquito midgut and migrate to salivary glands
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Components of the Malaria Life Cycle
Mosquito Vector
Human Host
Sporogonic cycle
Infective Period
Mosquito bitesgametocytemic person
Mosquito bitesuninfected person
Prepatent Period
Incubation Period
Clinical Illness
Parasites visible
Recovery
Symptom onset
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Clinical presentation
• Early symptoms– Headache– Malaise– Fatigue– Nausea– Muscular pains– Slight diarrhea– Slight fever, usually not intermittent
• Could mistake for influenza or gastrointestinal infection
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Clinical presentation
• Acute febrile illness, may have periodic febrile paroxysms every 48 – 72 hours with
• Afebrile asymptomatic intervals• Tendency to recrudesce or relapse over months to
years• Anemia, thrombocytopenia, jaundice,
hepatosplenomegaly, respiratory distress syndrome, renal dysfunction, hypoglycemia, mental status changes, tropical splenomegaly syndrome
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Malarial Paroxysm
• Can get prodrome 2-3 days before– Malaise, fever,fatigue, muscle pains, nausea, anorexia– Can mistake for influenza or gastrointestinal infection– Slight fever may worsen just prior to paroxysm
• Paroxysm– Cold stage - rigors– Hot stage – Max temp can reach 40-41o C,
splenomegaly easily palpable– Sweating stage – Lasts 8-12 hours, start between midnight and midday
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Malarial Paroxysm
• Periodicity– Days 1 and 3 for P.v., P.o., (and P.f.) - tertian– Usually persistent fever or daily paroxyms for
P.f.– Days 1 and 4 for P.m. - quartian
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Differential diagnosis
At the onset of the disease it may be very difficult to differentiate malaria from viral fevers.
Jaundice and fever is also seen in viral hepatitis and other forms of hepatitis, cholecystitis and hepatic
abscess.
Dengue, Leptospirosis and hemolytic anemia have the common triad of pallor, icterus and
splenomegaly.
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P. Falciparum-cerebral malaria:A symmetric encephalopathy
Whenever you see a patient who complains of headache, vomiting, diplopia, and is disoriented, confused or behaving abnormally then always
think MALARIA. The relatives may say that he is always sleepy and had a few convulsions.
On examination, varying levels of consciousness may be noted with divergent or convergent eyes, release of primitive reflexes, hyper/hyporeflexia,
hyper/hypotonia, extensor/flexor plantars and absent abdominals-cremasterics.
Signs of meningeal irritation may also be elicited.
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Cerebral Malaria-D/D
Always rule out other causes of altered sensorium like encephalitis, menigitis and
cerebral bleeds and infarcts.
Check for metabolic parameters and renal and hepatic failure as other diagnosis or as
contributing to reduced alertness or convulsions
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As the disease progresses
The patient becomes more drowsy and breathless suggesting ALI and ARDS.The O2 concentration
starts to drop and respiratory alkalosis sets in. Eventually he may be started on mechanical
ventillation.
The kidneys start to fail and urine output lessens signifying acute renal failure.
Shock,hypoglycemia, lactic acidosis and DIC complete the picture of MOSF.
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Chronic malaria - tropical splenomegaly
• Anorexia, nausea, vomiting, weight loss
• Symptoms due to anemia – pancytopenia
• Abdominal pain
• Abdominal lump
• Splenic rupture
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Tropical splenomegaly
• Patient from endemic area
• Many attacks of malaria in childhood
• Moderate to massive hepatosplenomegaly
• Smear negative for parasites
• Malarial antibodies positive
• Parasites in bone marrow
• Hypersplenism
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Tropical splenomegaly – diff diagnosis
• Kala-azar
• Portal hypertension – hepatic, extrahepatic
• Myeloproliferative diseases
• Lymphomas
• CLL
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Chronic complications of malaria
Tropical splenomegaly with or without hypersplenism is very common.
Immunological complications like nephrotic syndrome and a predisposition to Burkitt’s
lymphoma have also been reported.
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Diagnosis - malaria
A high index of suspicion is required and a history of visit to a malarious tract should always be sought by direct questioning of the patient or accompanying persons.A history of recent blood transfusion may point to an iatrogenic mode of
spread of malaria.
Thick and Thin smears should always be examined and indirect evidence of malaria by demonstrating
hemolytic jaundice should be performed.
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Other tests
Generally the complete blood counts and platelets counts are of little benefit in the diagnosis but aid in assessing the severity and complications of the
ongoing infection.
PfHRP2 dipstick or card test: monoclonal ab captures the parasite antigens. Only for falciparum
malaria.LDH dipstick or card test
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Drugs used to treat Malaria-First group
• CHQ, Amiodaquine
• Quinine, Quinidine
• Mefloquine, Halofantrine
• Lumefantrine
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First group-adverse reactions
GI disturbances-nausea, vomiting, diarrhoea and erosive or hemorrhagic gastritis with abdominal
pain and hematemisis at times.
Cardiovascular instability- Prolonged QTc ventricular tachyarrythmia and hypotension
CNS-disorientation, abn behaviour, seizureMetabolic- hypoglycemia
ALWAYS CHECK – K, MG, SUGAR before starting
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Drugs used to treat malaria
• Doxy, Tetra – pregnancy, children, hepatic
• Sulfadoxine-Pyrimethamine – sulfa allergy, renal failure
• Artemisin derivatives - safe
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Drugs used to treat Malaria-others
• Clindamycin
• Azithromycin
• Proguanil
• Dapsone
• Primaquine
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How to select antimalarials
Type of malaria – vivax or falciparum?
Sensitive or resistant
Associated renal or liver damage
Associated metabolic-electrolyte imbalances
Pregnancy, weight
Drug reactions
Oral therapy possible?
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Intravenous anti-malarial therapy- Indications
Presence of vomiting
Inability to start oral therapy may also be due to altered mental alertness and seizures.
Patients who are intubated and on ventillators.
Those who are critically ill.
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Intra-venous therapy
Chloroquine: intravenous 10 mg/kg max 600mg over 6-8 hrs followed by 15mg/kg max 900mg over next 24 hrs as slow infusion.
Quinine : intravenous 20mg/kg over 4 hrs; then 10mg/kg(max 600mg)three times a day.
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Intra-venous therapy-severe f.malaria
Artesunate 2.4mg/kg stat; followed by 2.4mg/kg at 12 hrs, 24hrs and then daily. OR
Artemether 3.2mg/kg stat im; then 1.6mg/kg od im.
PLUS
Add quinine 20mg salt/kg over 4 hrs; followed by 10mg/kg over 2-8 hrs slow infusion thrice a day.
PLUS
Doxy 100mg bd / tetra 250mg (4mg/kg) qds
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Oral therapy-CHQ sensitive malaria
Chloroquine 10mgbase/kg stat followed by 5mg/kg at 12, 24 and 36 hrs.
OR
Chloroquine 10mg/kg stat; then 10mg/kg at 24hrs and 5mg/kg at 48 hrs.
OR
Amodiaquine 10mg base/kg od x 3 days
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Oral therapy-sensitive f.malaria
Sulfadoxine-pyrimethamine 25mg/kg (max 1500mg of sulfadoxine) single dose
PLUS
Artesunate 4mg/kg od x 3 days
OR
Amodiaquine/CHQ plus artesunate
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Multidrug resistant malaria
Mefloquine 8mg base/kg orally od for 3 days, or 15mg/kg and then 10mg/kg next day
PLUS
Artemether-lumefantrine (1.5/9mg/kg bid) or artesunate 4mg/kg od for 3 days
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Multidrug resistant malaria- 2nd line
Doxy 100mg bd (3mg/kg x 7 days)Artesunate 2mg/kg od or quinine 10mg/kg tds PLUS1 drug of the following:Tetra 250mg qds (4mg/kg qid x 7 days)Clindamycin 10mg/kg bd x 7 days or
atovoquone-proguanil 20/8 mg/kg od x 3 days
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Other supportive therapy
• Maintain acid-base balance
• Maintain blood sugar
• Add folvite for hemolysis
• Blood transfusions
• Exchange transfusion
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DISEASES SPREAD BY MOSQUITOS
• MALARIA
• DENGUE FEVER
• YELLOW FEVER
• VIRAL ENCEPHALITIS
• VIRAL HEMORRHAGIC FEVERS
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MalariaMalaria
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Malaria (cont’d)Malaria (cont’d)• Avoid mosquitoes by taking protective measures.Avoid mosquitoes by taking protective measures.
• Use protective clothing: long sleeved shirts/pants.Use protective clothing: long sleeved shirts/pants.
• Use DEET repellant.Use DEET repellant.
• Use bed netting if rural or if locked windows not available.Use bed netting if rural or if locked windows not available.
• Prophylactic medications when indicated are widely used based Prophylactic medications when indicated are widely used based on CDC recommendations for intended destinations.on CDC recommendations for intended destinations.
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chemoprophylaxis
• Chloroquine 5mg base/kg (max 300 mg) once a week. Begin 1-2 weeks before travel, during stay and continue till 4 weeks after returning from malarious area.
• Mefloquine 5mg salt/kg (max 250 mg) once a week. Regime same as above.
• Atovoquone/proguanil (250/100mg) 1 tab for travel to resistant malarious area beginning 1-2 days before travel and taken daily during stay and ctd till 1 week after return from malarious area.
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Travel in Chloroquine Resistant areas Atovaquone/proguanil (Malarone) • 250 mg atovaquone and 100 mg proguanil hydrochloride.• Begin 1-2 days before travel and continue daily for 7
days after leaving the area.. • Daily, at the same time each day .• Contraindicated in persons with severe renal impairment • Contraindicated in children <5 kg, pregnant women, and
women breastfeeding.• Side effects- abdominal pain, nausea, vomiting, and
headache
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Congenital malaria• Transplacental infection
– Can be all 4 species– Commonly P.v. and P.f. in endemic areas– P.m. infections in nonendemic areas due to long persistence of species
• Neonate can be diagnosed with parasitemia within 7 days of birth or longer if no other risk factors for malaria (mosquito exposure, blood transfusion)
• Fever, irritability, feeding problems, anemia, hepatosplenomegaly, and jaundice
• Be mindful of this problem even if mother has not been in malarious area for years before delivery