Case• P.W a 34 years old female, no co-morbidities, no alcohol or smoking, Resident at Miti Mirefu• Presented to us c/o – Fever alt with chills but no rigors – Global throbbing headache – Generalized joint pains but no swelling – No nausea nor vomiting – No anorexia • Duration of symptoms 1 day
Case Cont’• On examination, – Was febrile, no pallor, jaundice or lymphadenopathy – V/S=Temp 37.8celsius, RR 18/min, PR-74min – S/E essentially normal – What are your differentials?
DDx• Malaria• Typhoid fever• Viral Illness• Occult Bacteria infection – What Lab test would you order and why?
Labs• Bs for MPS – Rule in Malaria=possibly 3 slides(WHO malaria guidelines)• Widal titers – Rising Titers=consecutive days=1:40 both• CBC – Look at Hb-11.2, Plts-146, WBC-7, Neutrophils-63%, Lymphocytes-46% slightly raised• Urinalysis – Bilirubin-+1, blood-trace, Nitrates =-ve and leukocytes=-ve – How will you Manage this patient?
Case Continue• Started on Paracetamol 1 g TID for 5 days• Advised to come back if symptoms persist on new ones develop
Case Continued• Came after 1 day still complaining of; – Headache – Fever this time high grade alt with chills – Generalized joint pains – Anorexia, nausea but no vomiting • O/E Febrile, no pallor, no jaundice • V/S Temp-38.9 Celsius – S/E essentially normal – What Tests would order?
Life cycle 1. oocysts in stomach wall 2. sporozoites in salivary glands 3. liver phase 4. merozoites from liver 5. Gametocytes
Treatment of uncomplicated P. falciparum malaria• ACTs recommended for treatment of:• Uncomplicated P. falciparum malaria – artemether plus lumefantrine, – artesunate plus amodiaquine, – artesunate plus mefloquine, – artesunate plus sulfadoxine-pyrimethamine.• Artemisinin and its derivatives should not be used as monotherapy.• Second-line anti-malarial treatment: – Alternative ACT known to be effective in the region – Artesunate plus tetracycline or doxycycline or clindamycin for 7 days – Quinine plus tetracycline or doxycycline or clindamycin for 7 days.
Case Continued• Suppose the same patient had 500/200WBC count or was Vomiting• How would you Manage this patient?
Treatment of severe malaria• For adults, artesunate IV or IM: – quinine is an acceptable alternative if parenteral artesunate is not available.• For children (especially in the malaria endemic areas of Africa) : – artesunate IV or IM; – quinine (IV infusion or divided IM injection); – artemether IM (should only be used if none of the alternatives are available).• Give parenteral Antimalarials for a minimum of 24 h, once started (irrespective of the patient’s ability to tolerate oral medication earlier) give complete course of: – an ACT; – artesunate plus clindamycine or Doxycycline; – quinine plus clindamycine or Doxycycline.• To complete treatment
Artemisinin-based regimens• Artesunate 2.4 mg/kg IV as 1st dose followed by 2.4 mg/kg at 12 and 24 hours followed by 2.4 mg/kg once daily for six days• OR Artemether 3.2 mg/kg IM followed by 1.6 mg/kg daily for six days• OR Artemisinin suppositories 40 mg/kg intra- rectally followed by 20 mg/kg at 24, 48 and 72 hours followed by an oral Antimalarials drug
Treatment of uncomplicated P. vivax malaria• Chloroquine + primaquine treatment of choice for Chloroquine-sensitive infections.• In mild-to-moderate G6PD deficiency, primaquine 0.75 mg base/kg given once a week for 8 weeks.• In severe G6PD deficiency, primaquine is contraindicated.• Where ACT (exception AS+SP) is the first-line treatment for P. falciparum malaria, in combination with primaquine for radical cure.• Artesunate plus sulfadoxine-pyrimethamine is not effective against P. vivax in many places
Treatment of uncomplicated P. falciparum malaria in special risk groupsPregnancy• First trimester: – quinine plus clindamycin for 7 days (artesunate plus clindamycin for 7 days if this treatment fails) – ACT indicated only if is the only treatment available, or if treatment with 7-day quinine plus clindamycin fails or uncertainty of compliance with a 7-day treatment.• Second and third trimesters: – ACTs known to be effective region or artesunate plus clindamycin given for 7 days, or quinine plus clindamycin for 7 days.Lactating women:• Standard antimalarial treatment (including ACTs) except for dapsone, primaquine and tetracyclines.Infants and young children:• ACTs for first-line attention to accurate dosing and ensuring administered dose retention.Travellers returning to non-endemic countries: – atovaquone-proguanil; – artemether-lumefantrine; – quinine plus doxycycline or clindamycin.