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Edit Comment Close Premium member Presentation Transcript Malaria - Update : Malaria - Update Dr.Girish Vaswani (D.N.B. med) Consulting Physician Bhatia hospital Motiben Dalvi Kothari Hospital Plasmodium species which infect humans : Plasmodium species which infect humans Plasmodium vivax ( B. tertian) Plasmodium ovale ( B. tertian) Plasmodium falciparum ( M.tertian) Plasmodium malariae (quartian) Slide 3: Exo- erythrocytic (hepatic) cycle Malaria Life Cycle Life Cycle Schizogony Sporogony Malaria Transmission Cycle : 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 Components of the Malaria Life Cycle : Components of the Malaria Life Cycle Mosquito Vector Human Host Sporogonic cycle Infective Period Mosquito bites gametocytemic person Mosquito bites uninfected person Prepatent Period Incubation Period Clinical Illness Parasites visible Recovery Symptom onset Clinical presentation : Clinical presentation Early symptoms Headache Malaise Fatigue Nausea Muscular pains Slight diarrhea Slight fever, usually not intermittent Could mistake for influenza or gastrointestinal infection Clinical presentation : 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 Malarial Paroxysm : 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 Malarial Paroxysm : 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 Differential diagnosis : 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. P. Falciparum-cerebral malaria:A symmetric encephalopathy : 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. Cerebral Malaria-D/D : 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 As the disease progresses : 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. Chronic malaria - tropical splenomegaly : Chronic malaria - tropical splenomegaly Anorexia, nausea, vomiting, weight loss Symptoms due to anemia – pancytopenia Abdominal pain Abdominal lump Splenic rupture Tropical splenomegaly : 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 Tropical splenomegaly – diff diagnosis : Tropical splenomegaly – diff diagnosis Kala-azar Portal hypertension – hepatic, extrahepatic Myeloproliferative diseases Lymphomas CLL Chronic complications of malaria : 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. Diagnosis - malaria : 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. Other tests : 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 Drugs used to treat Malaria-First group : Drugs used to treat Malaria-First group CHQ, Amiodaquine Quinine, Quinidine Mefloquine, Halofantrine Lumefantrine First group-adverse reactions : 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, seizure Metabolic- hypoglycemia ALWAYS CHECK – K, MG, SUGAR before starting Drugs used to treat malaria : Drugs used to treat malaria Doxy, Tetra – pregnancy, children, hepatic Sulfadoxine-Pyrimethamine – sulfa allergy, renal failure Artemisin derivatives - safe Drugs used to treat Malaria-others : Drugs used to treat Malaria-others Clindamycin Azithromycin Proguanil Dapsone Primaquine How to select antimalarials : 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? Intravenous anti-malarial therapy- Indications : 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. Intra-venous therapy : 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. Intra-venous therapy-severe f.malaria : 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 Oral therapy-CHQ sensitive malaria : 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 Oral therapy-sensitive f.malaria : 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 Multidrug resistant malaria : 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 Multidrug resistant malaria- 2nd line : Multidrug resistant malaria- 2nd line Doxy 100mg bd (3mg/kg x 7 days) Artesunate 2mg/kg od or quinine 10mg/kg tds PLUS 1 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 Other supportive therapy : Other supportive therapy Maintain acid-base balance Maintain blood sugar Add folvite for hemolysis Blood transfusions Exchange transfusion DISEASES SPREAD BY MOSQUITOS : DISEASES SPREAD BY MOSQUITOS MALARIA DENGUE FEVER YELLOW FEVER VIRAL ENCEPHALITIS VIRAL HEMORRHAGIC FEVERS Malaria : Malaria Malaria (cont’d) : Malaria (cont’d) Avoid mosquitoes by taking protective measures. Use protective clothing: long sleeved shirts/pants. Use DEET repellant. Use bed netting if rural or if locked windows not available. Prophylactic medications when indicated are widely used based on CDC recommendations for intended destinations. chemoprophylaxis : 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. Travel in Chloroquine Resistant areas : 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 Congenital malaria : 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 You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.