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Malaria Original Diagnosis And Management In Adults
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Malaria Original Diagnosis And Management In Adults

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  • 1. MALARIA 2
    malaria in adults diagnosis and management
  • 2. Plasmodium falciparum
    Most common cause of severe- life threatening malaria. Kills over 0ne million people annually
    Affects all ages
    Mortality depends on age, immunity etc complications and access to effective treatment
    Mortality is higher in adults than in children
  • 3. SEVERE MALARIA IN ADULTS
    Non immune ---travellers
    Return to endemic area after prolonged absence
    Stopping prolonged life-long prophylaxis
    HIV patients
    Pregnant women
  • 4. Pathophysiology
    Mainly effects on Bood and capillaries.
    1)HAEMOLYSIS --ALWAYS
    Therefore --ALL TISSUES --- ANOXIA
    2)Infected red cells adhere to capillary walls
    esp brain, gut, lungs, kidneys---ANOXIC DAMAGE
    3)Toxins from liberated shizonts further damage
    MALARIA--MULTIORGAN INVOVEMENT
  • 5. DIAGNOSIS- Clinical
    Great mimic of diseases common in the tropics
    Great index of suspicion in all febrile conditions esp if cause not obvious
    In many cases not dramatic start --insidious --malaise , headache, vomitting
    Cough & diarrhoea
    Fever--no pattern and may not be high
  • 6. Diagnosis
    Jaundice
    Dark urine
    Tender hepatosplenomegaly
    Some apparently not so ill pts can develop severe malaria ie serious complications
    HISTORY
    TRAVEL history -- within and from without
    Transfusion
    Injection (contaminated needle)
  • 7. Differential diagnosis of severe malaria
    Septicaemia
    Typhoid fever,
    Pyelonephritis
    Influenza,
    Lobar pneumonia
    Viral hepatitis
    Meningitis
    Encephalitis esp in non-immune.
    Drug effects and poisoning
  • 8. Features indicating severe malaria
    CLINICAL FEATURES
    Impaired consciousness
    Respiratory distress, acidosis, ARDS, pulmonary oedema
    Jaundice
    Bleeding
    Shock or circulatory collapse
  • 9. HAEMATOLOGICAL FEATURES
    Parasitaemia= or more than 5% or +3 or more
    Haemoglobin less than 6g/l or haematocrit less than 20%
    5% or more neutrophils contain malaria pigment
    Presence of schizonts of P falciparum in peripheral blood smear
    Evidence of DIC
  • 10. TREATMET uncomplicated
    Amodiaquine –artesunate combination – (oral) National recommendation for three days.
    Not recommended for pregnant women in 1st trimester May be used after 1st trimester
    Use quinine oral for pregnant women 600m oral 8hly for 7days
  • 11. Alternative to artimisimin-amodiaquine
    Artimisimin-lumefantrine----(coartem)
    Safer more expensive.
    Lumefantrine is not cardiotoxic, does not lower BP and no reported serious neurological or haematological complications
  • 12. Principles of management of severe malaria
    SPECIFIC ANTIMALARIALS-- parenteral
    Symptomatic support
    Management of complications
  • 13. Chemotherapy
    Quinine dihydrochloride--IV slow loading dose infusion over 4 hours (NEVER BOLUS) omit LD if pt has had quinine, quinidine or halofantrine in preceeding 24hrs or mefloquineinpreceeding 7 days
    followed by maintenamce dose 8 hourly in dextrose solution infused over 4-6 hrs
    Replace iv with oral after 48hrs
    Total duration 7-10 days.
    ECG if possible
  • 14. ALTERNATIVE TO QUININE
    Intramuscular artemisimin --artemether slow absorption from im depot
    Faster parasite clearance
    Not cardiotoxic
    Limited studies but as effective as quinine
    No advantage in mortality
    Further evaluation
  • 15. Problems with antimalarial drugs
    Chloroquine --high resistance rate Ghana about 20%
    Quinine – good for severe malaria.. Cardio depressnt, hypotension and arrythmias.
    Mefloquine --good but some resistance, cardiac depressant and neuropsychiatric adverse effects
    Halofantrine – can cause death from arrythmias but good antimalarials no in wide use.
    Lumefantrine. Good, has no cardiac depressant effects but expensive . Marketted with artisunate as Co-actem.
    Sulphadoxine-Pyrimethamine not recommended to individuals sensitive to sulphonamides or individuals with G6PD deficiency.
  • 16. Intermittent Preventive Treatment IPT used to prevent malaria in pregnancy (1)after 16 weeks SP therapeutic dose 3 tablets. 2) second dose one month later (3) Third dose one month later.
    Danger of sp folate deficiency, hypersensitivity
    Amodiaquine– similar to chloroquine, hypotension and syncope common, dystonicreations observed in Ghana, agranulocytosis reported in Western countries.
    Artimisimin derivatives effective. No reported resistance and no major adverse reactions. expensive
  • 17. General Measures severe malaria
    Good nursing
    Exclude other treatable causes of coma
    Rapid initial check of blood sugar frequent checks
    Monitor fluid balance avoid over & and under hydration
    Monitor urine output and look for haemoglobiuria
    Reduce temp by sponging avoid asprin & NSAID
    Look for associated infections and Rx
    Look for complications
  • 18. COMPLICATIONS
    DAMAGE DUE TO ANOXIA
    Brain
    Kidneys (acute tubular necrosis)
    Lungs :cough pulmonary oedema
    Intestine: diarrhoeacongestion,leakinnes to bacteria
    Liver: jaundice may- encephalopathy
  • 19. Complications
    Intravascular haemolysisBlackwater fever
    Shock hypotensive
    Septcaemic shock
    Hypoglycaemiaesp with quinine Rx or in pregnancy
    Metaboliic acidosis rare in adults
    Splenic rupture
    DIC
    In pregnancy maternal death abortion, still birth low birth wt
  • 20. Adult mortality high
    Renal failure
    Pulmonary oedema
    Cerbral complications for non immune
    In Pregnancy