K.L. Chhun, U. Vallery, Y. Chantana, BEAT RICHNER

Kantha Bopha Academy for Pediatrics

Siem Reap- Angkor

Malaria is one of the most common infectiousdiseases and an enormous public health problem.

The disease has been recognized for thousandsof years and it is widespread in tropical and subtropical regions, including parts of theAmericas, Asia, and Africa.

Currently, malaria occurs in about 100 countries and territories inhabited by a total of 2.4 billion people.

WHO estimates that there are 350 million to 500 million cases of malaria worldwide annually,

Of which 270 million to 400 million are Falciparum malaria, the most severe form of the disease, resulting approximately 1.5 million to 3 million deaths.

90% of the deaths are in children under five years of age. Other risk groups include pregnant women, internally displaced persons and refugees, and international travelers.

The human suffering and economic costs are enormous.

Malaria is still the main cause of morbidity and mortality among children in Cambodia.

A delay of treatment and/or inappropriate treatment are responsible of the high rate of lethality.

Malaria is complex but it is a curable and preventable disease.

Lives can be saved if the disease is detected early and adequately treated.

Mass education and appropriate organization of health facilities with well trained staffs can reduce

the mortality.

How People get Malaria ?

Malaria is caused by a parasite called Plasmodium, which is transmitted via the bites of infected mosquitoes. In the human body, the parasites multiply in the liver, and then infect red blood cells.

Usually, people get malaria by being bitten by an infective female Anopheles mosquito. When a mosquito bites an infected person, a small amount of blood is taken in which contains microscopic malaria parasites.

About 1 week later, when the mosquito takes its next blood meal, these parasites mix with the mosquito's saliva and are injected into the person being bitten.

Because the malaria parasite is found in red blood cells of an infected person, malaria can also be transmitted through blood transfusion, organ transplant, or the shared use of needles or syringes contaminated with blood.

Malaria may also be transmitted from a mother to her unborn infant before or during delivery("congenital" malaria).

Malaria Symptoms

Symptoms of malaria include fever and shakingchills, headache, muscle aches, tiredness and nausea, vomiting, and diarrhea may also occur.

Malaria cause anemia and jaundice because of the destruction of red blood cells. Symptoms usually appear between 10 and 15 days after

the mosquito bite.

If not treated, malaria can quickly become life-threatening by disrupting the blood supply to vital organs.

Infection with one type of malaria, Plasmodium falciparum, if not promptly treated, may cause kidney failure, seizures, mental confusion, coma, and death.

In many parts of the world, the parasites have developed resistance to a number of malaria medicines.

How soon will a person feel sick after being bitten by an infected mosquito?

For most people, symptoms begin 10 days to 4 weeks after infection, although a person may feel ill as early as 7 days or as late as 1 year later.

Two kinds of malaria, P. vivax and P. ovale, can occur again. In P. vivax and P. ovale infections, some parasites can remain dormant in the liver for several months up to bout 4 years after a person is bitten by aninfected mosquito.

When these parasites come out of hibernation and begin invading red blood cells ("relapse"), the person will become sick.

Infection with malaria parasites may result in a wide variety of symptoms, ranging from absent or very mild symptoms to severe disease and even death.

Malaria disease can be categorized as uncomplicated or severe complicated .

Malaria Incubation Period

The incubation period in most cases varies from 7 to 30 days.

The shorter periods are observed most frequently with

P. falciparum and the longer ones with P. malariae.

Antimalarial drugs taken for prophylaxis can delay the appearance of malaria symptoms by weeks or months. (This can happen particularly with P. vivax and P. ovale, both of which can produce dormant liver stage parasites; the liver stages may reactivate and cause disease months after the infective mosquito bite.)

Such long delays between exposure and development of symptoms can result in misdiagnosis or delayed diagnosis because of reduced clinical suspicion.

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Uncomplicated Malaria

The classical malaria attack lasts 6-10 hours. It consists of: Cold stage (sensation of cold, shivering) Hot stage (fever, headaches, vomiting; seizures in young

children) Sweating stage (sweats, return to normal temperature,

tiredness)

More commonly, the patient presents with a combination of the following symptoms:

Fever Chills Sweats Headaches Nausea and vomiting General malaise. Enlarged spleen.

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Enlargement of the liver Mild jaundice

Diagnosis of malaria depends on the demonstration of parasites on a blood smear examined under a microscope.

In P. falciparum malaria, additional laboratory findings may include anemia, decrease platelets, elevation of bilirubin, and hemoglobinuria.

Complicated malaria

Severe malaria occurs when P. falciparum infections are complicated by serious organ failures or abnormalities in the patient's blood or metabolism.

The manifestations of severe malaria include: Cerebral malaria, with abnormal behavior, impairment of

consciousness, seizures, coma, or other neurologic abnormalities

Severe anemia Hemoglobinuria Pulmonary edema or acute respiratory distress

syndrome Cardiovascular collapse and shock Acute kidney failure Metabolic acidosis Hypoglycemia .

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Severe malaria occurs most often in persons who have no immunity to malaria or whose immunity has decreased. These include all residents of areas with low or no malaria transmission, young children and pregnant women in areas with high transmission.

In all areas, severe malaria is a medical emergency and should be treated urgently and aggressively.

Study design:- Epidemiologic study- Critical signs and symptoms- Clinical features - Treatment- Underlining TB primary infection

Study period:-1st January 2008 to 31st December 2009

Patient criteria:-All patients hospitalized with positive blood

smear

Data collections

- Age distribution- Sex distribution- Geographical distribution- Seasonal distribution

Outcome Conclusion

1364 confirmed cases out of 73667 hospitalized patient represent

1.85% over two-year period from 2008 to 2009.

Number of not confirmed cases compared with all hospitalized patient

4140 suspected cases (smear negative) represent 4140 suspected cases (smear negative) represent 5.61% overover73667 cases of the year 2008 -2009.cases of the year 2008 -2009.

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Male : 729 ( 53% ) Female : 635 ( 47% )

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Geographical distribution

Critical signs and symptoms

• Severe anemia (HB< 7g/l)   : 586 (43%)

• Hypoglycemia  :

390 ( 28.59% )

• Acute renal failure   : 345 ( 25.85% )

• Metabolic acidosis   : 339 ( 24.85% )

• Respiratory distress : 254 ( 18.62% )

• Hemoglobinuria   : 124 ( 9% )

• Lung Edema : 7 ( 0.51% )

• Shock : 6 ( 0.43% )

• Digestive Hemorrhage with shock : 2 ( 0.14% )

• Conscious disturbance:    

- Lethargy : 481 (35.26%)

- Convulsion : 156 (11.43%)

- Delirium : 118 (8.65%)

- Coma : 36 (2.63%)

• Severe Malaria (falciparum) : 1064(78%)

• Cerebral Malaria (falciparum)

: 309(22.65%)

• Vivax Malaria : 302(22%)

• Mixed Malaria (falciparum + vivax)

: 55(4%)

• Plasmodium falciparum : 1062 (77.85%)

• Plasmodium vivax : 302 (22.14%)

• P falciparum+ vivax : 55 (4%)

Imaging

• Lungs CT scan: In 1023 (75%) over 1364 cases,

calcifications were detected.

Anti-malaria drugs:

- Artesunate for falciparum malaria:. D1: First dose 4mg/kg IV and 12hr later second dose

2mg/kg IV. D2-D5: 2mg/kg/d IV

- Quinine for Vivax malaria:. Dose 30mg/kg/d IVP for 7days

Symptomatic treatment Severe anemia:

- Hb< 7g/l or Ht< 20% Transfusion: 10-20ml/kg of RCC or WB

Hypoglycemia:- D50% 1-2ml/kg 1 part + sterile water 4 part or D10%:

5ml/kg Convulsion:

- Valium: 0.5mg/kg IR or 0.2-0.5mg/kg IVP- Phenobarbital: 10-20mg/kg IV

ARF:- Furosemide: 0.5-2mg/kg/dose (maximum 6mg/kg/dose)

Treatment of TB primary infection

Rifater (Isoniazid 80mg+rifampicin120mg+ pyrazinamide 250mg):

1 tablet/ 10kg for 6 months.

Deaths : 05 (0.36%) 1359 cases : good outcome without sequelae.

Complicated malaria is presented with one or more of the ten main clinical manifestations: 1-severe anemia,2-hypoglycemia,3- acute renal failure,4-metabolic acidosis,5-cerebral malaria,6-hemoglobinuria,7-respiratory distress,8-lung edema,9-shock, and 10- digestive hemorrhage with shock.

Complicated malaria is a medical emergency and so it requires early diagnosis and prompt treatment.

• The absence of fever or a negative blood smear should not exclude complicated Malaria. • Severe anemia is the predominant clinical symptom of complicated malaria (43%)

=>blood transfusion necessary.

• Children in the age range from 1 to 5 are predominantly affected.

• 75% of the present cases have underlining TB primary infection.