Malaria Original Diagnosis And Management In Adults


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Malaria Original Diagnosis And Management In Adults

  1. 1. MALARIA 2<br />malaria in adults diagnosis and management<br />
  2. 2. Plasmodium falciparum<br /> Most common cause of severe- life threatening malaria. Kills over 0ne million people annually<br />Affects all ages<br />Mortality depends on age, immunity etc complications and access to effective treatment<br />Mortality is higher in adults than in children<br />
  3. 3. SEVERE MALARIA IN ADULTS<br />Non immune ---travellers<br />Return to endemic area after prolonged absence<br />Stopping prolonged life-long prophylaxis<br />HIV patients<br />Pregnant women <br />
  4. 4. Pathophysiology<br />Mainly effects on Bood and capillaries.<br />1)HAEMOLYSIS --ALWAYS <br />Therefore --ALL TISSUES --- ANOXIA<br />2)Infected red cells adhere to capillary walls<br />esp brain, gut, lungs, kidneys---ANOXIC DAMAGE<br />3)Toxins from liberated shizonts further damage<br />MALARIA--MULTIORGAN INVOVEMENT<br />
  5. 5. DIAGNOSIS- Clinical<br />Great mimic of diseases common in the tropics<br />Great index of suspicion in all febrile conditions esp if cause not obvious<br />In many cases not dramatic start --insidious --malaise , headache, vomitting<br />Cough & diarrhoea<br />Fever--no pattern and may not be high<br />
  6. 6. Diagnosis<br />Jaundice<br />Dark urine<br />Tender hepatosplenomegaly<br />Some apparently not so ill pts can develop severe malaria ie serious complications<br />HISTORY<br />TRAVEL history -- within and from without<br />Transfusion<br />Injection (contaminated needle)<br />
  7. 7. Differential diagnosis of severe malaria<br />Septicaemia<br />Typhoid fever,<br />Pyelonephritis<br />Influenza,<br />Lobar pneumonia<br />Viral hepatitis<br />Meningitis<br /> Encephalitis esp in non-immune.<br /> Drug effects and poisoning<br />
  8. 8. Features indicating severe malaria<br />CLINICAL FEATURES<br />Impaired consciousness<br />Respiratory distress, acidosis, ARDS, pulmonary oedema<br />Jaundice<br />Bleeding<br />Shock or circulatory collapse<br />
  9. 9. HAEMATOLOGICAL FEATURES<br />Parasitaemia= or more than 5% or +3 or more<br />Haemoglobin less than 6g/l or haematocrit less than 20%<br />5% or more neutrophils contain malaria pigment<br />Presence of schizonts of P falciparum in peripheral blood smear<br />Evidence of DIC<br />
  10. 10. TREATMET uncomplicated<br />Amodiaquine –artesunate combination – (oral) National recommendation for three days.<br />Not recommended for pregnant women in 1st trimester May be used after 1st trimester<br />Use quinine oral for pregnant women 600m oral 8hly for 7days <br />
  11. 11. Alternative to artimisimin-amodiaquine<br />Artimisimin-lumefantrine----(coartem)<br />Safer more expensive.<br />Lumefantrine is not cardiotoxic, does not lower BP and no reported serious neurological or haematological complications<br />
  12. 12. Principles of management of severe malaria<br />SPECIFIC ANTIMALARIALS-- parenteral<br />Symptomatic support <br />Management of complications<br />
  13. 13. Chemotherapy<br />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<br />followed by maintenamce dose 8 hourly in dextrose solution infused over 4-6 hrs<br />Replace iv with oral after 48hrs <br />Total duration 7-10 days. <br />ECG if possible<br />
  14. 14. ALTERNATIVE TO QUININE<br />Intramuscular artemisimin --artemether slow absorption from im depot<br />Faster parasite clearance <br />Not cardiotoxic<br />Limited studies but as effective as quinine<br />No advantage in mortality<br />Further evaluation<br />
  15. 15. Problems with antimalarial drugs<br />Chloroquine --high resistance rate Ghana about 20% <br />Quinine – good for severe malaria.. Cardio depressnt, hypotension and arrythmias.<br />Mefloquine --good but some resistance, cardiac depressant and neuropsychiatric adverse effects<br />Halofantrine – can cause death from arrythmias but good antimalarials no in wide use.<br />Lumefantrine. Good, has no cardiac depressant effects but expensive . Marketted with artisunate as Co-actem.<br />Sulphadoxine-Pyrimethamine not recommended to individuals sensitive to sulphonamides or individuals with G6PD deficiency. <br />
  16. 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.<br />Danger of sp folate deficiency, hypersensitivity<br />Amodiaquine– similar to chloroquine, hypotension and syncope common, dystonicreations observed in Ghana, agranulocytosis reported in Western countries. <br />Artimisimin derivatives effective. No reported resistance and no major adverse reactions. expensive<br />
  17. 17. General Measures severe malaria<br />Good nursing<br />Exclude other treatable causes of coma<br />Rapid initial check of blood sugar frequent checks<br />Monitor fluid balance avoid over & and under hydration <br />Monitor urine output and look for haemoglobiuria<br />Reduce temp by sponging avoid asprin & NSAID<br />Look for associated infections and Rx<br />Look for complications<br />
  18. 18. COMPLICATIONS<br />DAMAGE DUE TO ANOXIA<br />Brain<br />Kidneys (acute tubular necrosis)<br />Lungs :cough pulmonary oedema<br />Intestine: diarrhoeacongestion,leakinnes to bacteria<br />Liver: jaundice may- encephalopathy<br />
  19. 19. Complications<br />Intravascular haemolysisBlackwater fever<br />Shock hypotensive<br />Septcaemic shock <br />Hypoglycaemiaesp with quinine Rx or in pregnancy<br />Metaboliic acidosis rare in adults<br />Splenic rupture<br />DIC<br />In pregnancy maternal death abortion, still birth low birth wt<br />
  20. 20. Adult mortality high<br />Renal failure<br />Pulmonary oedema<br />Cerbral complications for non immune<br />In Pregnancy<br />