incidence,cinical features and CBIMCI guidelines

1. Malaria

2. Introduction
• ‘mal’ aria = bad air (Italian word)
• 3.3 billion people (41%) are at risk
• Every 30 seconds a child dies of malaria
• World Malaria Day: 25th April

3. Etiology
• Organisms:
– Plasmodium vivax
– Plasmodium ovale
– Plasmodium malariae
– Plasmodium falciparum
• Vector:
– Female Anopheles mosquito
– ( A. culcifacies, A. stephensi, A. minimus)
• Mode of Transmission:
– Mosquito bite
– Blood transfusion
– Contaminated needles
– Vertical transmission

4. Malaria in Nepal

5. Prevalance of Malaria
Splenic Index:
Rate of palpable spleen in children between the
ages of 2-10 years.
<10%: low incidence
>50%: hyperendemic
>75%: holoendemic
Parasite Rate:
Percentage of children between 2-10 years
who show malarial parasites in their blood

6. Exo-
erythrocytic
(hepatic) cycle
Sporozoites
Mosquito Salivary
Gland
Malaria Life
Cycle
Life Cycle
Gametocytes
Oocyst
Erythrocytic
Cycle
Zygote
Schizogony
Sporogony
Hypnozoites
(for P. vivax
and P. ovale)

7. Pathophysiology
• Fever
– Release of merozites
• Anaemia
– Hemolysis
– Sequesteration in spleen
– Bone marrow suppression Organ Failure
• Tissue anoxia
– Cytoadherance of erythrocytes to the endothelium
• Hypoglycemia/ Acidosis
– Anaerobic metabolism

8. Immunity
• Innate:
• Hemoglobin S sickle cell trait or disease
• Hemoglobin C and hemoglobin E
• Thalessemia – α and β
• Glucose – 6 – phosphate dehydrogenase
deficiency (G6PD)
• Absence of Duffy coat antigen
• Acquired:
– Transferred from mother to child
– Protects in first 3 mnths

9. Clinical Features
• Incubation Period
– P. falciparum = 9-14 days
– P. vivax = 12-17 days
– P. ovale = 16-18 days
– P. malariae = 18-40 days
• Prodrome
– Headache, anorexia, myalgia, fever, joint pain

10. • Febrile Paroxysms
– Coincides with the release of schizonts
– P. vivax/ovale = 48 hrs
– P. malariae = 72 hrs
• COLD STAGE:
– Chills, rigor
– Headache, nausea, vomitting
• HOT STAGE:
– Dry, flushed skin
– Rapid breathing
• SWEATING STAGE:
– Fever decreases by crisis

12. • Non-immune children
– High grade fever
– Nausea, vomiting, diarrhoea, anorexia
– Prostration
– Pallor, cyanosis
– Hepatosplenomegaly
• High-endemic zone
– Milder symptoms
– Markedly enlarged liver and spleen
– Early manifestations of complications

13. • RECRUDESCENCE:
– Occurance after primary attack
– Survival of erythrocyte forms in the blood
stream
– P. malariae, P. falciparum
• RELAPSE:
– Release of merozoites from exo-erthrocytic
cycle
– P. vivax, P. ovale
• RECURRENCE:
– exo-erythrocytic forms infect erythrocytes,
separate from previous infection (all species)

14. Congenital malaria
• Occur in endemic areas
• Abortions, stillbirth, prematurity, IUGR
• Present in 10-30 days of life
– fever
– Restlessness, drowsiness
– Pallor, jaundice
– Poor feeding, vomiting
– hepatosplenomegaly

15. Complications
• Cerebral malaria:
– sequesteration of capillaries with parasitized erythrocytes
– thrombosis of cerebral vessels
• Fatality rate = 20-40%
• Parasitemia >5%
– Altered sensorium, delirium, hallucination
– Headache, Deep coma
– High fever
– Seizure, Hemiplegia
– UMNL features
– CSF= Normal
– Hypoglycemia has bad prognosis

16. • Renal failure:
– Decrease in renal blood flow
– Acute tubular necrosis
– Deposits of hemoglobin in renal tubules
• Blackwater Fever:
– Severe hemolysis
– Hemoglobinuria
– Renal failure

17. • Algid malaria:
– Overwhelming infection of P. falciparum
– hypotension, hypothermia
– Circulatory collapse, shock
• Anemia
• Thrombocytopenia
• Hypoglycemia
• Pulmonary oedema
• Splenic rupture

18. Diagnosis
• Peripheral Smear (gold standard)
– Thick smear
– Thin smear
• Quantitative Buffy coat

19. • Rapid Diagnostic tests
– OptiMAL test
– Immunochromatographic test
– Detects parasite LDH
• PCR
• Immunofluroscence Assay
• Bone Marrow Aspiration
• CBC, RBS, RFT, LFT, PT, Urine RME

20. Differential Diagnosis
• Typhoid
• Anicteric hepatitis
• Septicemia
• UTI/ Pyelonephritis
• Pnemonia
• Liver abscess
• Infective endocarditis
• Meningitis/ Encephalitis
• Shock
• Kala-azar
• Tuberculosis
• Leukemia
• Collagen vascular
Disease

21. Treatment
• Uncomplicated Malaria
• Chloroquine Phosphate
– 10mg (base)/kg stat
– 5mg (base)/kg at 6, 24 and 48 hrs
• Primaquine
– 0.75mg/kg on D1 (P. falciparum)
– 0.25mg/kg for 14 days (P. vivax, ovale)

22. • Second line drugs
– Artesumate Sulphapyrimethamine
– Oral Quinine
– Mefloquine
– Atovaquone- proguanil
– Clindamycin
– Doxycyclin

23. • Severe Malaria:
• Immediate Management:
– ABC management
– Assess GCS
– Correct hypoglycemia, dyselectrolytemia
– Mx of unconscious patient
– Mx of raised ICP

24. • Antimalarial therapy:
• Quinine dihydrochloride
– 20mg (salt)/kg in 5% Dx over 4hrs IV
– 10mg (salt)/kg over 4hrs every 8hrly
– Once the child can take orally;
– Oral Quinine: 10mg/kg/dose 8hrly for 7days
• Artesumate (IV)
– 2.4mg/kg stat then 1.2mg/kg at 12, 24 hrs
• Artemether (IM)
– 3.2mg/kg stat the 1.6mg/kg at 12,24 hrs

25. • Supportive care:
– Antibiotics
– Anticonvulsants
– Blood transfusions
– Dialysis
– Fluid and Electrolytes balance
– Ionotropic support
– Correction of hypoglycemia
– Correction of raised ICP
– Mechanical ventilation

26. Prevention
• Reducing exposure to infected mosquitos
– Insecticides
– Mosquito repellants and creame
– Permethrin Rxed mosquito net
– Full sleeved clothings
– Drainage of stagnant water bodies
– Gambusia fish

28. • Chemoprophylaxis
• Chloroquine
– 5mg (base)/kg every weekly
– 1-2 weeks before and 4 weeks after entering an
endemic zone
• Chloroquine resistant: Mefloquine
• Vaccination
– Under development
– RTS,S (Mosquirix)

29. Summary