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management of malaria

management of malaria



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Malaria Malaria Presentation Transcript

  • OVERVIEW AND MANAGEMENT Presented by : Capt Vikramjit Singh Moderator : Lt Col R Sivasubramanian
  • .
  • . The word Malaria comes from 18th century Italian mala meaning “bad” and aria meaning “air”. Also known as jungle fever, marsh fever, paludal fever. According to WHO, the majority of death occur among children in sub-saharan Africa killing an African child every 30 second. Associated and cause of poverty and obstacle to economic development.
  • Discovery Dr. Alphonse Laveran, a military doctor in France armed forces health service discovered malarial parasite M.H. Algeria in 1880. Also won a Nobel prize for the same in 1907. Later Sir Ronald Ross ,born in India, a British doctor discovered malarial parasite in GIT of anopheles mosquito that led to realization of cause.(Calcutta)
  • EPIDEMIOLOGY Malaria is a protozoan disease. Transmitted through bite of female anopheles mosquito. most important parasitic ds. transmission in 108 countries containing 3 billion people causing 1-3 million deaths each year
  • .Problem of resurgence due to>drug resistance of parasites>insecticides resistance to vectors
  • . Malaria can behave as epidemic in country like India ,Sri lanka, se asia Most prevalent when there are Climate changes such as heavy rains following drought or migrations(refugees or workers) When there is breakdown in control and preventive services
  • DETERMINANTS1.density2.human biting habits3.longevity of anophelesmosquito must survive >7 days to transmit
  • . New control and research are promising but malaria remains today as it has been for centuries i.e a heavy burden on tropical communities, a threat to non malarious or non endemic area , a danger to travelers
  • ETIOPATHOGENESIS Genus : plasmodium Species :falciparum :vivax :ovale :malariae :knowlesi(in macaques,can also in humans) deaths mainly due to falciparum
  • 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 for years without causing sickness. and can cause relapse.
  • Plasmodium Falciparum Most serious form of disease 20- 30 % cases in India
  • BRIEF LIFE CYCLE from mosquito Sporozoites into human blood . than into liver there occurs pre-erythrocytic schizogony. Single Sporozoites>10,000-30,000 daughter Merozoites.>burst> released into blood Taken up by RBCs male female gametes also found into blood
  • 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
  • SYMPTOMS fever chills rigors corresponds to erythrocytic stage Severity depend upon 1.type of parasite 2.immunity of patient 3.function of spleen
  • TRANSMISSIONplasmodium > give rise to > gametes(in blood)which can be taken up by female anophelesresponsible for transmission
  • 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(no dormant(hypnozoite )) So relapse don’t occur here Recrudescence may occur due to incomplete clearance of parasites by drug.
  • SPECIES DIFFERENCES Pl. Pl.vivax Pl.ovale Pl.malaria falciparumNo. of 30,000(>2%pa 10,000 15,000 15000merozoites rasitemia isrelease/inf s/o Pl.falcihepatocytesDuration of 48 48 50 72erythrocyticcycleRbc pref YOUNG RETICULO RETICULO OLDER CYTES CYTES CELLSRELAPSE NO YES YES NOIncubation 9-14 12-18 12-18 18-40period(days)
  • 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
  • HEADACHE may be severe in malaria no photophobia no neck rigidity
  • MYALGIA not usually as severe as dengue not tender as in leptospirosis/typhus
  • FEVER classical finding of spikes, chills, rigors at regular interval are unusual may suggest P.vivax or P.ovale P.Falciparum fever is irregular .and generalized seizure associated with it fever may rise above 40 degree Celsius tachycardia , delirium
  • Cerebral malaria Coma Death rate~20% Diffuse symmetric encephalopathy ~15% of patient have retinal hemorrhages on fundoscopy Generalized convulsions 10% of adults(<3% with sequelae) 50% of children(>5% with sequelae like hemiplegia, cerebral palsy, cortical blindness, deafness, language defects, increased epilepsy incidence, decreased life span.
  • SEVERE FALCIPARUM MALARIA SIGNS unarousable coma acidosis severe anemia(normochromic/normocytic) renal failure pulmonary edema ARDS hypoglycemia shock or hypotension DIC convulsions Haemoglobinuria(black water fever)
  • POOR PROGNOSTIC FACTORS CLINICAL marked agitation respiratory distress hypothermia bleeding deep coma repeated convulsions anuria Shock(algid malaria)
  • POOR PROGNOSIS {LAB VALUES} Hypoglycemia(<40mg/dl) Acidosis(ph<7.3 , hco3<15 mmol/l) Elevated s.creatinine(>3mg/dl) Elevated bilirubin Elevated liver enzymes(AST/ALT >3X) Elevated CPK Elevated urate
  • Poor prognosis wbc >12000/ul severe anemia(pcv<15%) Coagulopathy decreased platelet prolonged PT >3 sec prolonged PTT decreased fibrinogen(<200 mg/dl)
  • INVESTIGATION Hb Total leukocytes count Differential leukocytes count platelets Peripheral blood film Rapid malarial test Serum urea Serum creatinine
  • Diagnosis Thick blood film Thin blood film {rapid ,species specific inexpensive} Rapid pfhrp2(monoclonal antibody) {+ means illness in falciparum} Plasmodium ldh rapid test Microtubule conc. method with Acridine Orange Stain
  • RMT
  • DRUGS 1.schizonticides>> Primary tissue(prophylaxis)>> Erythrocytic(for acute attacks and prophylaxis)>> Exo-erythocytic(radical cure) 2.gametocides(prevent transmission)
  • 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
  • . Chloroquine 300mg base once weekly begin 1 week before take weekly continue up to 4 weeks after leaving
  • .Doxycycline 100 mg qd begin 2 day before take daily Continue up to 4 week after leavingContraindication : in child <8yr ,pregnantSide effects : photosensitivity, diarrhea
  • . Mefloquine 250mg salt po weekly begin a week before take weekly continue up to 4 weeks after leavingContra indication: allergic history to this drug, psychiatric conditions, cardiac conduction abnormalities
  • .Primaquine 30mg of base po qd begin 1 day before travel take daily continue up to 7 days after leaving also used for presumptive anti relapse therapy(terminal prophylaxis) Contra indication:g6pd def icienc ypregnanc y and lactation
  • UNCOMPLICATED MALARIA Chloroquine sensitive Dose 10 mg of base /kg stat f/b 5 mg /kg at 12,24,36 hour or 10 mg/kg at 24 hour >>5 mg/kg at 48 hour or Amodiaquine 10 mg of base/kg qd for 3 days
  • RADICAL TREATMENT FOR OVALE AND VIVAX in addition to Chloroquine and Amodiaquine Primaquine 0.50mg of base/kg qd for 14 days prevents relapse In mild g6pd deficiency 0.75 mg of base /kg given weekly for 7 weeks
  • SENSITIVE FALCIPARUM Artesunate 4mg/kg qd for 3 days + Sulphadoxine 25 mg/kg, Pyrimethamine 1.25 mg /kg as single dose or Artesunate 3 days + Amodiaquine 3 days (4mg/kg ) (10mg/kg)
  • MULTI DRUG RESISTANTFALCIPARUM Artemether-Lumefantrine b.d for 3 day 1.5mg/kg 9 mg/kg or Artesunate plus Mefloquine 8mg/kg for 3 days or 15mg/kg 2nd day f/b 10mg/kg 3rd day
  • 2nd line t/t or t/t of importedmalaria Artesunate or Quinine for 7 days (2mg/kg) (10mg/kg) plus one of following 1.Tetra4/Doxycycline 3mg/kg for 7 days 2.Clindamycin 3mg/kg for 7 days or Atavaquone-proguanil qid for 3 days 20 mg/kg 8 mg/kg
  • SEVERE FALCIPARUM MALARIA Artesunate (2.4mg/kg) intravenous stat followed by same dose at 12 and 24 hour It is drug of choice when available or Artemether (3.2mg/kg)stat intramuscular f/b 1.6 mg/kg qd
  • Severe Falciparum Quinine dihydrochloride(20 mg /kg)infused over 4 hour f/b slow infusion of 10mg/kg infused over 2-8 hour q8h(8hourly) or Quinidine(10mg/kg)infused over 1-2hour f/b 1.2mg/kg per hour with ECG monitoring
  • 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
  • WHO RECOMMENDED ACTs Artemether-lumefantrine{COARTEM} Artesunate-mefloquine Artesunate-amodiaquine Artesunate-sulfadoxine-pyrimethamine Dihydroartemisinin-piperaquine
  • COMPLICATIONS Acute renal failure(tubular necrosis) Acute pulmonary edema ( non cardiogenic) Hypoglycemia(hepato gluconeogenesis failure) DIC (only in <5%) Aspiration pneumonia in comatose
  • OTHER COMPLICATIONS Mild jaundice to severe in falciparum . Hepatic dysfunction contributes to hypoglycemia, lactic acidosis, impaired drug metabolism Anemia (accelerated RBC removal by spleen , obligatory destruction due to schizogony , ineffective erythropoiesis) Transfusion malaria due to needle stick injury and transfusion(short incubation period due to absence of pre erythrocytic stage of development
  • DEGREE OF RESISTANCE WHO SCHEME study of parasitemia over 28 days smears on day 2,7 and 28 days grade r1,r2,r3 normal response >if parasite count falls to <25%of pre treatment value by 48 hours and smears be negative by 7 days
  • Factors1.longer half life2.single mutation for resistance.3.poor immunity5.number of people using these drug
  • Possible points which help to reduce emergence of resistance 1.use conventional drugs first in uncomplicated cases 2.avoid drug with longer half life 3.avoid basic antimalarials for conditions like RA in endemic area 4.ensure compliance 5.monitor resistance and early treatment to prevent spread 6.clear policy of using new drugs 7.use of combinations
  • Preventing malaria Avoiding mosquito bites -vector control . -reducing contact between people and vectors -improving living standards, screened windows, air conditioning. -ITNs(insecticide-treated bed nets)
  • References HARRISON’S PRINCIPLES OF INTERNAL MEDICINE 18th edition Centers for Disease Control and Prevention (website) WHO(website)