Malaria - Ilyani

8/2/2019 Malaria - Ilyani

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Nurul Ilyani bt Jamaluddin

41216


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A disease caused by the presence of the sporozoan

Plasmodium in human

transmitted by the bite of an infected female

Anopheles mosquito that previously sucked the blood

from a person with malaria.

4 important species of Plasmodium:

Plasmodium falciparum

Plasmodium vivax Plasmodium malariae

Plasmodium ovale


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In Malaysia,

Mainly in Perak, Pahang, Kelantan, Sabah and Sarawak.

But the incidence gradually declining over the year.


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Sporozoites (infective form) transmitted during the blood-

meal feeding of a female Anopheles mosquito on a human.

The sporozoites invade and reside within hepatocytes where

they multiply to large numbers.

An. maculatus P. Malaysia

An. balabacensis Sabah

An. donaldi Sarawak


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1 . uncomplicated malaria (all species) Fever, chill, headache, malaise and myalgia

Malarial paroxysm: rigor and fever followed byprofuse diaphoresis and exhaustion occuring at

regular interval tertian, quartan etc are seldomseen.


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3 Phases Total duration 8 - 12 hours1) Cold, chill stage 15 60 min, rigors and

chattering teeth.

2) Hot 2-6 hours temp 39 41 0C3) Sweating 2-4 hours drenching, profuse, feverdeclines, symptoms diminish and exhaustion.

The fever paroxysm corresponds to the period oferythrocyte rupture and

merozoite invasion.

Vivax\Ovale


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Severe anemia DIVC

ARF Urine < 0.5ml/kg/hr, failing to improve after

rehydration and creatinine > 265mmol/L

Pulmonary oedema

ARDS

Hypoglycemia Quinine and quinidine can induce hyperinsulinemia

Severe metabolic acidosis


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Hyperkalemia (K >5.5 mmol/l) Cerebral malaria

Dexamethasone and mannitol are contraindicated

Repeated generalized convulsion

Algid malaria Hypotension (systolic < 70mmhg), cold clammy

skin.. CVP, fluid resus, inotrope

? Possibility of complicating septicemia if +persistent hypotension > bld C+S and antiobiotic If pt is on IV quinine or quinidine, consider drug

induced cardiac depression.


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Hyperparasitemia P.falciparum in peripheral blood > 5% of

erythrocytes or > 250,000/ul

Worse prognosis, need IV chemotx or exchange

tranfusion Hyperpyrexia

Rectal temp > 40c

Tx : sponging, rectal PCM 0.5-1g every 4 hour

Jaundice Se.bilirubin > 50umol/l


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Visualization of parasite on Giemsa-stainedthin and thick smears.

May be undetected initially as parasitized redcells are often sequestered from the bloodstream

Require repeated smears twice daily for 3/7to fully exclude malaria


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FBC, ESR, BUSE, LFT, RP ABG, CXR, UFEME

G6PD screened before the use ofprimaquine

Blood c+s

UPT


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Chloroquine 10mg base/kg of BW (not exceed 600mg) followed

by 5mg/kg 6-8 hr later and 5mg for next 2/7 Usual adult regime : 600mg followed by 300mg 6hr

later and 300mg/day for next 2/7. In resistence case, add doxycyline/tetracycline plus

primaquine

Primaquine Eradicate hypnozoite

Usual adult dose : 15 mg daily for 2/52 G6PD deficeincy pt : 30-45mg weekly for 8/52 Contraindicated in pregnancy


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Chloroquine (as above) Fansidar

SDX/PYR (sulfadoxine 500mg/ pyrimethamine25mg per tab) given single dose, usually 3 tabs

Contraindicated in prengnant women n infant

Primaquine 30-45mg single dose in adult with normal G6PD for

gametocidal action


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Quinine (600mg tds for 1/52) with either; Fansidar : 3tabs as single dose

Doxycycline: 100mg salt daily for 1/52

Tetracycline: 250mg qid for 1/52

Primaquine (as above)


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Loading dose: IVI 20mg/kg quinine salt over4 hour

Initial maintaince: 10mg/kg quinine salt over4hr tds

Adjustment consideration: Pt remains seriously ill after 3/7 (reduce dose by

30-50%) QT interval prolonged by 25% Liver or renal impairment Hypotension n arrthymia Good oral intake give oral quinine


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Repeat blood smear daily (BD in severe infx) Within 48-72 hr after starting tx, pt usually

become afebrile and clinically improved

upon recovery, blood film should berepeated once/month to ensure norecrudescence.


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Leptospirosis is a zoonosis of worldwide

distribution High-risk areas include south-east asia. Seasonal outbreaks associated with changes

in local water levels have been described;

-flood Recreation; water sports, ingestion of water

and food contaminated with leptospirosis.

Inoculation through skin abrasions


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Caused by Leptospira interrogans (gramve).

Appears to be ubiquitious in wildlife andmany domestic animals, most frequent hostsare rodents.

The bacterium persists in convoluted tubulesof the kidney and are shed into the urine inmassive numbers


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Incubation period averages 1-2 weeks.

In 90% of cases, leptospirosis manifests asan acute febrile illness with a biphasic

course. 1st phase- Septicaemic phase 2nd phase- immune phase


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Occurs during the 1st week of infection Characterized by

Sudden onset of high and remittent fever with chillsand rigors (38-40c)

Retro-orbital headache Conjuctival congestion

Myalgia (paraspinal, calf and abdominal muscle)

Maculopapular skin rash

vomiting


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Usually 1st phase symptoms improve first(defervescence) before going into the nextphase

Occurs 1-4 weeks after infection

Immune phase characterized by asepticmeningitis (50%), and in severe cases Weilsdisease.

Systemic manifestation is common such as

nephritis, hepatitis, myocarditis and ARDS Mortality : 10-15%


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Pallor Conjuctival congestion

Jaundice

Muscle tenderness Rashes

Hepatosplenomegaly

lymphadenopathy


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http://images.google.com.my/imgres?imgurl=http://www.lph.go.th/lab/Image/lepto2.jpg&imgrefurl=http://www.lph.go.th/lab/html/leptospirosis2.html&h=177&w=256&sz=99&tbnid=o8I8kQt_D50J:&tbnh=73&tbnw=106&start=24&prev=/images?q=Leptospirosis&start=20&hl=en&lr=&sa=N


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Serum/urine C & S test Can be cultured from blood during 1st week of

illness and from urine 2-4 weeks of illness

Microscopic examination

Thick smears stained by Giemsas technique will bepositive

Serology detection of leptospira antibodies


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TW maybe normal or as high as 50,000/ul.Thrombocytopenia is uncommonUfeme: urine may contain bile, protein, cast and red cellsLFT: bilirubin and liver enzymesRP: creatinine in 50% of caseCSF: polymorphonuclear or lymphocytic pleocytosis with [protein]

and normal glucose


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General Close T, BP, PR, RR and I/O charting

Adequate hydration, keep temp < 38c

Antibotics for 1/52 Mild dz: Doyclycline 100mg bd or

Ampicillin/amoxicllin 1g qid

Severe dz: IV Penicillin G 1.5 mU qid or Ceftriaxone1g OD

Beware of Jarisch-Herxheimer rxn

Supportive Dialysis, ventilatory support etc


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Malaria - Ilyani