Malaria shrideep`s presantation

8/14/2019 Malaria shrideep`s presantation

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MALARIA

Malaria : Historical perspective

In 1880, Laveran, a French physician in Algeriaidentified causative organism of Malaria. Recd Nobel

Prize in 1907

August 20th 1897 Sir Ronald Ross, while workingin India demonstrated oocyst in gut of Anophelene

mosquito.This day is celebrated as Mosquito

Day


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Malaria - Facts sheet : 40% of world population ( > 240 Cr. people )

areexposed to malaria in 100 countries. WHO 1995

50 Cr. get it every year

10 L people die of malaria every year India contributes 80% of total cases

Orissa with only 3% of Indias population

contributes 25% of total reported cases ofmalaria in India

NMEP ( 1997 ) reported P Falcip 40% &

P Vivax 60%.


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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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Anopheles mosquito : Facts


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Exo-erythrocytic(hepatic) cycle

Sporozoites

Mosquito SalivaryGland

Malaria LifeCycleLife Cycle

Gametocytes

Oocyst

ErythrocyticCycle

Zygote

Schizogony

Sporogony

Hypnozoites

(for P. vivaxand P. ovale)


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Malaria Transmission Cycle

Parasite undergoes

sexual reproduction inthe mosquito

Some merozoites

differentiate into male orfemale gametocyctes

Erythrocytic Cycle:Merozoites infect red

blood cells to formschizonts

Dormant liver stages

(hypnozoites) ofP.vivax and P. ovale

Exo-erythrocytic (hepatic) Cycle:

Sporozoites infect liver cells and

develop into schizonts, which releasemerozoites into the blood

MOSQUITO HUMAN

Sporozoires injected

into human host duringblood meal

Parasites

mature in

mosquito

midgut and

migrate to

salivaryglands


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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


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Fever 1 month

Nausea 15 days


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Past H/O:Nothing contributory

Drug H/O:Tab. Ciprofloxacin

Travel H/O:He went to his village

(Kurigram) 7 days priorto fever

On Ex.:Temp. 102F

(chill and rigor)Pulse 120 /min.

BP 110 / 80 mmHg

RR 24 / min.JVP not raised

Pallor present

Jaundice mild (+)

Clubbing absent

Lymph node not palpable

Thyroid gland not palpable

Systemic Ex.:CVS - Normal

RS - Normal

GIT - Hepato splenomegaly

Other system revealed no abnormality


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Fever

Nausea

Malaria, Kalazar, Enteric

Hepatitis


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CBC:

ESR - 56 mm 1st hour

Hb% - 11.5 mg /dl

TLC - 3,480 /cumm[ (N) - 58%, (L) - 36%, No band ]

Widal:not significant

LFT:

T. Bilirubin - 37 umol/L ( )

Alka. Phos. - 94 u/L (~)

ALT - 68 u/L ( ) AST - 61 u/L ( )

Urine R/M/E:normal

X-ray Chest:

Normal

USG ofWhole Abdomen:

Hepato splenomegaly

Blood C/S:

No organism

ICT for Malaria: Positive


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Rapid Diagnostic Tests :Rapid Diagnostic Tests :

Assays for detection of pLDH : It is a soluble enzymeexpressed at high levels in asexual stages of malarialparasite. It is present in all four species of Plasmodium. 3antibodies are used to detect it. Two are for all 4 species ;

3rd is specific for P Falciparum. Sensitivity is similar to or less

than microscopy sp at


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WHO recommendations on

Rapid Diagnostic Tests :

These tests are recommended when microscopy not

available or inconclusive. These tests are fast & simple

They are fairly sensitive and specific

These tests are particularly helpful in partially treated cases

or when microscopy is negative The tests can be very useful when the patient reports after

the working hours

Monitoring parasite clearance, quantification of parasite

load, and stage identification is not possible with thesetests

THICK FILM SHOULD BE EXAMINED IN ALLSUSPECTED CASES OF MALARIA


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Clinical presentation : childrenClinical presentation : children

Anemia + + +

Convulsions + + +

Hypoglycemia + + +

Jaundice + Renal failure

Pulmonary edema +

Neurological sequelae aremore common (15%)


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P. falciparum

P. malariae

P. vivax

P. ovale


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Complications

Cerebral malaria

Hypoglycaemia

Hyperpyrexia

ConvulsionShock

Hemoglobinuria

Severe anaemia

Acute renal failure

Coagulopathy

Spontaneous bleeding

Acute pulmonary oedemaAspiration pneumonia

Hyperparasitaemia

Metabolic acidosis

Glomerulonephritis

Nephrotic syndrome

Herpes simplex

Relapses


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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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Aims of treatment :Aims of treatment : To kill allTo kill all schizontsschizonts as fast and as completely asas fast and as completely as

possible (we are not concerned much about gametespossible (we are not concerned much about gametesas they do not cause disease in the patient concerned,as they do not cause disease in the patient concerned,but cause transmission to others)but cause transmission to others)

To kill hepatic parasites (To kill hepatic parasites ( hypnozoiteshypnozoites in Pin P VivaxVivax ))which causes recrudescence or relapsewhich causes recrudescence or relapse

To treat other associated abnormalitiesTo treat other associated abnormalities


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Treatment

Plasmodium vivax:

Tab. Chloroquine (CQ) + Tab. Primaquine (PQ) CQ3 + PQ14

Uncomplicated Malaria

Presumptive

:

Tab. Chloroquine (CQ) CQ3

Severe Malaria :

IV Quinine drip / IM Quinine followed by

Oral Quinine for a total of 7 days

Or, IM Artemether / IV Artesunate followed by

Oral Artesunate tablet

Uncomplicated Malaria Confirmed

:

Tab. Co-artem (Artemether + Lumefantrine) 4 tab. 12H, 3 days

Or, Tab. Quinine 2 tab. 8H, 7 days

Alternative,

Tab. Quinine (Q) + Tab. Tetracycline (T) Q7 + T7

Or, Tab. Quinine (Q) + Tab. Doxycycline (D) Q7 + D7

Or, Tab. Artisunate (A) + Tab. Mefloquine (M) A3 + M2


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Plasmodium vivax:

Tab. Chloroquine (CQ) + Tab. Primaquine (PQ) CQ3 + PQ14


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More choices means moreMore choices means moreconfusion !!!confusion !!!


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QUININE :QUININE : INJ 300 mg / ml :INJ 300 mg / ml :

11STST DOSE 20 mg / kgDOSE 20 mg / kgThen 10 mg / kg B DThen 10 mg / kg B D

TAB 300mg / 600 mg ; 600 mg 8TAB 300mg / 600 mg ; 600 mg 8 hrlyhrly

CHILDREN 10 mg 8CHILDREN 10 mg 8 hrlyhrly FOR 7 DAYSFOR 7 DAYS

Side effects : hypotension, hypoglycemia,Side effects : hypotension, hypoglycemia,arryhthmiaarryhthmia


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CHLOROQUINE :CHLOROQUINE : TAB 250 mg / 500mgTAB 250 mg / 500mg

2 TAB ( 600 mg BASE ) STAT2 TAB ( 600 mg BASE ) STAT1 TAB AFTER 6 HOURS1 TAB AFTER 6 HOURS

1 TAB OD FOR 2 DAYS.1 TAB OD FOR 2 DAYS.

Prophylactic : 300 mg ( base ) / weekProphylactic : 300 mg ( base ) / week


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Mefloquine :Mefloquine :

250 mg Tab

Dose: 20 mg / kg in 1 or 2 doses

Good for combination therapy and

prophylactic therapy ( once a week )


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Primaquine :Primaquine :

Only effective drug against hypnozoites.

Thus to be used for radical cure of vivaxmalaria

Dose 15 mg / day for 15 days

Check for G 6 P D deficiency as it may

cause hemolysis in deficient people.


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Rapidly acting blood schizontocidal antimalarials

against chloroquine sensitive and chloroquine resistantfalciparum as well as vivax malaria

They quickly arrest the ring or the trophozoite

development and also prevent pathological sequelae

Fever subsides and parasites are cleared rapidly Defervescence occurs within 2-3 days after drug

administration

90% clearance of asexual erythrocytic

parasitaemia is usually observed within 4 hours

(Valecha N. et al., Indian Journal of Pharmacology, 1997)

Artemesinin:Artemesinin:


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Malaria and pregnancy :Malaria and pregnancy : Quinine, chloroquine, S P can be used safely in any

trimester.

Artesunate, artemether and mefloquine can be use in

IInd and IIIrd trimesters.

Clindamycin can be used in pregnancy.

Doxycycline and primaquine are contraindicated.


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Treatment of malaria in infants :Treatment of malaria in infants : Malaria is common in infants in endemic countries as

immunity from mother wanes after 46 months.

Case fatality rate is higher in infants than in older

children.

Dosing should be proper.

With increasing failure of chloroquine and SP challenge

is to find good drugs.

Luckily artemesinins are safe and well tolerated.

Even rectal administration could be done.


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Special consideration in childreSpecial consideration in childre

Fluid < 5 kgFluid < 5 kg ------ 150ml / kg / day150ml / kg / day

55 10 kg10 kg 120ml/kg/day120ml/kg/day

1111--19 kg19 kg 80 ml/kg/ day80 ml/kg/ day

Packed CellsPacked Cells ------ 20ml / kg over 320ml / kg over 3--4 hrs4 hrs


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WHO-Current and Future directionsDrug management of malaria

Malaria endemic countries which are experiencinghigh levels of resistance to currently used anti-malarial

drugs as monotherapy are advised to switch over to

combination therapy


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OTHER MEASURESOTHER MEASURES


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THANK YOU

SHRIDEEP PARAB

GROUP NO 33

6TH COURSE

ENGLISH MEDIUM

SARATOV-2010

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Malaria shrideep`s presantation