1. OVERVIEW AND MANAGEMENT Presented by : Capt Vikramjit SinghModerator : Lt Col R Sivasubramanian

2. . 3. . The word Malaria comes from 18th centuryItalian mala meaning bad and ariameaning air. Also known as jungle fever, marshfever, paludal fever. According to WHO, the majority of deathoccur among children in sub-saharan Africakilling an African child every 30 second. Associated and cause of poverty andobstacle to economic development. 4. Discovery Dr. Alphonse Laveran, a military doctor inFrance armed forces health servicediscovered malarial parasite M.H. Algeria in1880. Also won a Nobel prize for the same in 1907. Later Sir Ronald Ross ,born in India, aBritish doctor discovered malarial parasitein GIT of anopheles mosquito that led torealization of cause.(Calcutta) 5. EPIDEMIOLOGY Malaria is a protozoan disease. Transmitted through bite of femaleanopheles mosquito. most important parasitic ds. transmission in 108 countries containing 3 billion people causing 1-3 million deaths each year 6. .Problem of resurgence due to>drug resistance of parasites>insecticides resistance to vectors 7. . Malaria can behave as epidemic in countrylike India ,Sri lanka, se asia Most prevalent when there are Climatechanges such as heavy rains followingdrought or migrations(refugees or workers) When there is breakdown in control andpreventive services 8. DETERMINANTS1.density2.human biting habits3.longevity of anophelesmosquito must survive >7 days to transmit 9. . New control and research arepromising but malaria remains today asit has been for centuries i.e a heavy burden on tropicalcommunities, a threat to non malariousor non endemic area , a danger totravelers 10. ETIOPATHOGENESIS Genus : plasmodium Species:falciparum:vivax:ovale:malariae:knowlesi(in macaques,can also inhumans) deaths mainly due to falciparum 11. Plasmodium Vivax Plasmodium vivax milder form of disease,generally not fatal. About 60-70% of infections in India Has a liver stage and can remain in body foryears without causing sickness. and can cause relapse. 12. Plasmodium Falciparum Most serious form of disease 20- 30 % cases in India 13. TRANSMISSION CYCLESPOROZOITESIN MOSQUITO GUTLIVER GAMETE>ZYGOTE>OOKINETE MEROZOITESRBCs GAMETOCYTESSHIZONTS 14. BRIEF LIFE CYCLE from mosquito Sporozoites into human blood . than into liver there occurs pre-erythrocytic schizogony. Single Sporozoites>10,000-30,000 daughterMerozoites.>burst> released into blood Taken up by RBCs male female gametes also found into blood 15. PLASMODIUM primary development stage in >liver also called as Pre Erythrocytic stage responsible for cause of malaria then enter into rbc also called as Erythrocytic stage responsible for symptoms 16. SYMPTOMS fever chills rigors corresponds to erythrocytic stage Severity depend upon 1.type of parasite 2.immunity of patient 3.function of spleen 17. TRANSMISSIONplasmodium > give rise to > gametes(in blood)which can be taken up by female anophelesresponsible for transmission 18. RELAPSE and RECRUDESCENCE Some shizonts remain dormant in liver called as exo-erythrocytic hepatic stage Seen in vivax This stage is absent in pl.falciparum(nodormant(hypnozoite )) So relapse dont occur here Recrudescence may occur due toincomplete clearance of parasites by drug. 19. SPECIES DIFFERENCES Pl.Pl.vivax Pl.ovale Pl.malaria falciparumNo. of 30,000(>2%pa 10,000 15,000 15000merozoites rasitemia isrelease/infs/o Pl.falcihepatocytesDuration of48 48 50 72erythrocyticcycleRbc pref YOUNGRETICULO RETICULO OLDERCYTESCYTESCELLSRELAPSENO YESYESNOIncubation 9-14 12-1812-1818-40period(days) 20. CLINICAL FEATURES lack of sense of well being headache fatigue abdominal pain or discomfort muscle ache followed by fever (may look like viral ) nausea ,vomiting ,orthostatic hypotension 21. HEADACHE may be severe in malaria no photophobia no neck rigidity 22. MYALGIA not usually as severe as dengue not tender as in leptospirosis/typhus 23. FEVER classical finding of spikes, chills, rigorsat regular interval are unusual may suggest P.vivax or P.ovale P.Falciparum fever is irregular .andgeneralized seizure associated with it fever may rise above 40 degree Celsius tachycardia , delirium 24. Cerebral malaria Coma Death rate~20% Diffuse symmetric encephalopathy ~15% of patient have retinal hemorrhages onfundoscopy Generalized convulsions 10% of adults(5% with sequelae likehemiplegia, cerebral palsy, corticalblindness, deafness, language defects, increasedepilepsy incidence, decreased life span. 25. SEVERE FALCIPARUM MALARIASIGNS unarousable coma acidosis severe anemia(normochromic/normocytic) renal failure pulmonary edema ARDS hypoglycemia shock or hypotension DIC convulsions Haemoglobinuria(black water fever) 26. POOR PROGNOSTIC FACTORS CLINICAL marked agitation respiratory distress hypothermia bleeding deep coma repeated convulsions anuria Shock(algid malaria) 27. POOR PROGNOSIS {LAB VALUES} Hypoglycemia(12000/ul severe anemia(pcv3 sec prolonged PTT decreased fibrinogen(> Primary tissue(prophylaxis)>> Erythrocytic(for acute attacks and prophylaxis)>> Exo-erythocytic(radical cure) 2.gametocides(prevent transmission) 33. CHEMOPROPHYLAXIS Atavaquone(250mg)/Proguanil(100mg)po with milky drink and food begin 1 day before travel to malarious area take o.d. continue up to 7 day after leavingContra indication in renal failure, pregnancy n breastfeeding 34. . Chloroquine 300mg base once weekly begin 1 week before take weekly continue up to 4 weeks after leaving 35. .Doxycycline 100 mg qd begin 2 day before take daily Continue up to 4 week after leavingContraindication : in child >5 mg/kg at 48 hour or Amodiaquine 10 mg of base/kg qd for 3days 39. RADICAL TREATMENT FOR OVALE AND VIVAX in addition to Chloroquine andAmodiaquine Primaquine 0.50mg of base/kg qd for 14days prevents relapse In mild g6pd deficiency 0.75 mg of base /kggiven weekly for 7 weeks 40. SENSITIVE FALCIPARUM Artesunate 4mg/kg qd for 3 days+ Sulphadoxine 25 mg/kg, Pyrimethamine1.25 mg /kg as single doseor Artesunate 3 days + Amodiaquine 3 days (4mg/kg )(10mg/kg) 41. MULTI DRUG RESISTANTFALCIPARUM Artemether-Lumefantrineb.d for 3day 1.5mg/kg 9 mg/kg or Artesunate plus Mefloquine 8mg/kg for 3 daysor 15mg/kg 2nd day f/b 10mg/kg 3rd day 42. 2nd line t/t or t/t of importedmalaria Artesunate or Quinine for 7 days(2mg/kg)(10mg/kg) plus one of following1.Tetra4/Doxycycline 3mg/kg for 7 days2.Clindamycin 3mg/kg for 7 days or Atavaquone-proguanil qid for 3 days20 mg/kg 8 mg/kg 43. SEVERE FALCIPARUM MALARIA Artesunate (2.4mg/kg) intravenous statfollowed by same dose at 12 and 24 hour It is drug of choice when available or Artemether (3.2mg/kg)stat intramuscularf/b 1.6 mg/kg qd 44. Severe Falciparum Quinine dihydrochloride(20 mg/kg)infused over 4 hourf/b slowinfusion of 10mg/kg infused over 2-8 hourq8h(8hourly) or Quinidine(10mg/kg)infused over 1-2hourf/b 1.2mg/kg per hour with ECG monitoring 45. Supportive Treatment General care of the unconscious patient, Careful fluid balance, Control of seizures, Naso-gastric tube feeding, Correction of metabolic derangements(e.g. hypoglycaemia, metabolic acidosis) Blood transfusion for severe anaemia. Bacterial infection: antibiotics 46. WHO RECOMMENDED ACTs Artemether-lumefantrine{COARTEM} Artesunate-mefloquine Artesunate-amodiaquine Artesunate-sulfadoxine-pyrimethamine Dihydroartemisinin-piperaquine 47. COMPLICATIONS Acute renal failure(tubular necrosis) Acute pulmonary edema( non cardiogenic) Hypoglycemia(hepato gluconeogenesisfailure) DIC (only in if parasite count falls to