1. MD.Kiyumars Karimi MALARIA CLINICAL FEATURES

2. CLINICAL FEATURES First symptoms are non specific: Headache Fatigue Myalgia and Arthralgia Incubation period: Depends on species 8 to 25 days Affected by partial immunity Signs: Non specific Anemia Hepatolienal syndrome

3. Clinical Syndromes Acute disease Complicated Uncomplicated Chronic disease Asymptomatic

4. Acute Malaria Disease Malarial paroxysm stages: 1. Cold stage 2. Hot stage 3. Diaphoresis stage o Cold stage: Feeling of intense cold Vigorous shivering Lasts 15-30 minute Accompanied by headache, nausea & myalgia

5. Paroxysm stages o Hot stage: Intense Heat Dry burning skin Hypotension Lasts 15 minute to several hours o Sweating stage: Profuse sweating Declining temperature Exhaustion Lasts 2-4 hours

6. Complicated Malaria Cerebral Malaria Hypoglycemia Non Cardiogenic Pulmonary Edema Metabolic Acidosis Renal Impairment Hematological Disorders Liver Dysfunctions Hyperpyrexia Hyperparasitemia Hemoglobinuria

7. Cerebral Malaria Ominous feature of P.falciparum Sudden or gradual onset Diffuse symmetric encephalopathy Focal neurological deficit is uncommon Divergent eye and pout reflex is common Muscle dystonia Preserved corneal reflex except indeep coma Retinal hemorrhage in 15 % of patients Residual neurological defecit

8. Hypoglycemia Important and common complication Associated with poor prognosis Problematic in children and pregnant women Clinical diagnosis maybe difficult Causes: Hepatic gluconeogenesis failure Increase glucose consumption by host and lesser by parasite drug induced hypoglycemia

9. Acidosis Important cause of death Results from organic acid accumulation Hyperlactatemia coexist with hypoglycemia Acidotic breathing is a sign of poor prognosis Bicarbonate or lactate are best biochemical prognosticators Causes: Anaerobic glycolysis Hypovolemia Lactate production by the parasites Failure of hepatic and renal lactate clearance

10. Noncardiogenic Pulmonary Edema May develops even after antimalarial therapy. More common in adults. Mortality rate is >80% Predisposing factors: Renal failure Pregnancy Hyper parasitemia Pathogenesis: Exact pathogenesis is unclear. Pulmonary microvascular obstruction and increased TNF . Aggravated by vigorous administration of IV Fluid.

11. Renal impairment More common among adults. High mortality (upto 45%) May occur with other vital-organ dysfunction. Manifest as Acute tubular necrosis. Renal cortical necrosis never develops Pathogenesis: Exact pathogenesis is unclear. May related to microcirculatory obstruction.

12. Other Complications Anemia results from: Accelerated RBC removing by spleen RBC destruction by schizont Ineffective erythropoiesis Liver Dysfunction Hemolytic jaundice is common. sever with P.falciparum infection. Pathogenesis: Hemolysis Hepatocyte injury Cholestasis

13. Malaria in Pregnancy Pregnant women prone to sever infection. Common adverse effect on foetal: Stillbirths Fetal distress LBW IUGR Prematurity Maternal effect: Maternal anemia Higher mortality from cerebral malaria Premature labor

14. Malaria in Children Mortality is more in children. May present with labored deep breathing Long term neurocognitive & developmental deficit Conditions rare in child: Deep jaundice Acute renal failure Acute pulmonary edema