Malaria Clinical Cases Presentation :Malaria Clinical Cases Presentation


Information requested when evaluating a potential case of malaria :Information requested when evaluating a potential case of malaria Age Sex and pregnancy status Travel history, travel outside major or urban areas Visitors from endemic areas Exposure to mosquitoes Malaria prophylaxis used Receipt of blood transfusions or transplant Past history of malaria Drug allergies Clinical status of the patient, esp. neurological Lab results


Case 1 :Case 1 31 yo female returned home to South Florida on January 18, 1996 following a 16-day trip to Bolivia No antimalarial chemoprophylaxis taken; had significant rural exposure on trip Upon returning home she developed fever, chills, headache and malaise and was admitted that same day to Hospital A and evaluated for sepsis


Case 1 :Case 1 Treated with IV antibiotics administered through a heparin lock Blood films obtained on January 23, 1996 were positive for P.v., later confirmed at CDC The patient was treated with oral chloroquine and primaquine, improved promptly, and was discharged on January 24, 1996


Case 2- Congenital malaria :Case 2- Congenital malaria Previously healthy 10-week old female developed an fever and dark urine on September 7, 2000 Temp 103.7o F, WBC 24,600/µl, and Hb 8.7 g/dL She was admitted for possible sepsis Blood, urine, and cerebral spinal fluid cultures were done Treated with IV ampicillin and cefotaxime


Case 2- Congenital malaria :Case 2- Congenital malaria Past medical history Uncomplicated pregnancy and delivery Seen in ER on July 17 for abnormal breathing Normal exam and chest Xray, no diagnosis made or treatment given Parents from DR Congo- dad came in 1995, mom in 1996 Mom completed course of chloroquine prior to immigration for malaria (?self-diagnosis)


Case 2- Congenital malaria :Case 2- Congenital malaria Smears taken on September 8 showed P.m. Treatment with chloroquine was started She received 2 units of packed RBCs after Hgb dropped to 5.6 g/dL Responded well to treatment with negative smears 1 week post therapy


Case 2- Congenital malaria :Case 2- Congenital malaria Parents denied any episodes of malaria febrile illness foreign travel or blood transfusion since in US Lived in screened apartment, some mosquitoes seen indoors in August Friend from Kinshasha visited in August, he was well during visit


Case 2- Congenital malaria :Case 2- Congenital malaria Pretreatment labs on mother Blood smears were negative Positive IgG titers P.f. and P.m. 1:16,384 P.v. and P.o. 1:102 PCR - negative Mother was treated empirically with chloroquine


Slide 10:Gold standard: Multiple thick and thin smears Dip stick tests CBC Anemia Leukopenia, or leukocytosis No eosinophilia DIAGNOSIS


Diagnosis :Diagnosis Thick and thin blood smears are gold standard Identify species and quantify density If can not identify species, treat for P.f. Re-examine smears or use alternative diagnostic tool Suspect P.f. If critically ill, suspect P.f. If returned from Sub-Saharan Africa, > 95 % chance of P.f. pure or mixed infection Parasitemia > 1% Doubly infected cells


Slide 14:Drugs Used to Treat Malaria Chloroquine (Aralen, Dawaquine) Amodiaquine (Camoquine) Quinine and Quinidine Sulfa combination drugs (Fansidar, Metakelfin) Mefloquine (Lariam) Halofantrine (Halfan) Atovaquone-proguanil (Malarone) Atemisinin derivatives (Paluther)


All “malaria” is not malaria :All “malaria” is not malaria Incubation periods unlikely Parasite density very high for nonfalciparum Species not likely given travel history Drug resistance? Misdiagnosis – species or parasite or negative Miscalculation of density Previously undetected mixed infection


Malaria! :Malaria! Remember: Flu-like Symptoms + ‘Recent’ Hx Travel To Malarious Area = Think Malaria


Summary :Summary Mosquito-borne infectious disease Tropics, subtropics P. falciparum, vivax, ovale, malariae Incubation period nearly two weeks Cyclic paroxysms Fever Thick and think blood smears for diagnosis


Summary :Summary Drug resistance is increasing Chemoprophylaxis can prevent infection Carefully screen people when prescribing mefloquine Great importance of personal protective measures Aggressive monitoring needed to enforce ppm at command level Regard and manage malaria as medical emergency


Control Of Malaria :Control Of Malaria Global eradication efforts by WHO in 1950s Efforts now focus on CONTROL vs. ERADICATION


Points Of Attack :Points Of Attack 1. Attack the parasite in the human host 2. Reduce contact between humans and mosquitoes 3. Decrease mosquito population


Points Of Attack :Points Of Attack 1. Attack the parasite in the human host 2. Reduce contact between humans and mosquitoes 3. Decrease mosquito population


Attack The Parasite In The Human Host :Attack The Parasite In The Human Host Treat malaria infections with effective medications Use prophylactic drugs to prevent illness and/or infection


Attack The Parasite In The Human Host :Attack The Parasite In The Human Host Chemoprophylaxis is based on current drug resistance patterns MEFLOQUINE first line prophylaxis Mefloquine 250 mg po q week, 1-2 wks prior to 4 wks after DOXYCYCLINE as second line drug Doxy 100 mg po qd, 2 days prior to 4 wks after PRIMAQUINE 30 mg* po qd x 14 days terminal prophylaxis *15 mg per FDA and drug product information insert


New Antimalarial for Prophylaxis: Atovaquone/Proguanil (Malarone®) :New Antimalarial for Prophylaxis: Atovaquone/Proguanil (Malarone®) Licensed July 2000 in USA for treatment and prophylaxis of P. falciparum Atovaquone is a blood schizonticide Proguanil is metabolized to cycloguanil, a tissue schizonticide Combination very effective for treatment of multi-drug resistant P. falciparum Generally well tolerated with >95% efficacy vs. placebo


Dosage of Malarone® :Dosage of Malarone® Prophylaxis dose: one tablet per day Start 1-2 days prior to entering endemic area Continue for one week after leaving (causal prophylaxis, kills parasites in liver) Adult formulation: 250 / 100 mg atovaquone / proguanil in single combination tablet Pediatric formulation: 62.5 / 25 mg single tablet


Who Should Use Malarone® for Prophylaxis? :Who Should Use Malarone® for Prophylaxis? Persons on short trips who wish to avoid a long course of medication after return Persons concerned about drug side effects Persons traveling to areas where resistance to other drugs may occur Persons who prefer a daily regimen


Reduce Contact Between Humans And Mosquitoes :Reduce Contact Between Humans And Mosquitoes Personal protective measures Proper wearing of uniform DEET PERMETHRIN Bed nets


Reduce Contact Between Humans And Mosquitoes :Reduce Contact Between Humans And Mosquitoes Personal protective measures Proper wearing of uniform DEET PERMETHRIN Bed nets


Slide 29:Decrease Mosquito Population Surveillance of mosquito populations Identify and eliminate breeding sites Proper insecticide application Attack larval stages Attack adult mosquito