Malaria

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Malaria

  1. 1. Malaria By Dr. Osman Sadig
  2. 2. <ul><li>Malaria: </li></ul><ul><li>- is a m ajor health problem in developing tropical countries: </li></ul><ul><li>1- Annual incidence of 300– 500 x 1000 000 </li></ul><ul><li>2- 1% mortality , mainly in under 5 years , </li></ul><ul><li>pregnant ladies & non immune </li></ul><ul><li>3- 80% of cases & 90% of deaths in AFRICA. </li></ul><ul><li>- In Sudan :- </li></ul><ul><li>1- 250/ 10 000 population/ year (7.5 million/ </li></ul><ul><li>year </li></ul><ul><li>2- 35 000 deaths every year </li></ul>
  3. 3. <ul><li>3- 20—40% of health institute attendance </li></ul><ul><li>4- 20—30% of total hospital admissions </li></ul><ul><li>5- 15—20% of total deaths </li></ul><ul><li>6- 22% loss of working hours </li></ul><ul><li>Organism:- </li></ul><ul><li>- Plasmodium falciparum ( 95% in Sudan) </li></ul><ul><li>- P. vivax </li></ul><ul><li>- P. ovale </li></ul><ul><li>- P. malariae </li></ul><ul><li>** P. falcip is endemic in the tropics , has no </li></ul><ul><li>hypnozoites to sustain transmission which </li></ul><ul><li>depends on the presence of vector all za year. </li></ul>
  4. 4. <ul><li>** P.f invades RBC of all ages, multiple </li></ul><ul><li>RBC infection is common & mature trophoz </li></ul><ul><li>are absent in the peripheral </li></ul><ul><li>blood. </li></ul><ul><li>** P.f is the only sp. of malaria associated with </li></ul><ul><li>life threatening complications & is often </li></ul><ul><li>drug resistant </li></ul><ul><li>** P.v. & P.o. are endemic in the temperate </li></ul><ul><li>zones, invade reticulocytes & cause relapsing </li></ul><ul><li>malaria. </li></ul><ul><li>** P.m. produces chronic low parasitaemia. </li></ul>
  5. 5. <ul><li>** 5—7% of infections are multiple with more </li></ul><ul><li>than one sp. </li></ul><ul><li>** Light microscopy of stained BF is used to </li></ul><ul><li>diagnose malaria & identify the sps. </li></ul><ul><li>Transmission </li></ul><ul><li>1- Female anopheles mosquito (A. gambiensis </li></ul><ul><li>and A. arabiensis). Transmission depends on </li></ul><ul><li>the presence of gametocytes in the peri blood </li></ul><ul><li>2- BT & sharing needles . No relapse with this </li></ul><ul><li>mode of transmission </li></ul><ul><li>3- Transplacental Congenital malaria </li></ul>
  6. 6. <ul><li>Epidemiology </li></ul><ul><li>Transmission of malaria depends on the presence of:- </li></ul><ul><li>1- Infected reservoir </li></ul><ul><li>2- Susceptible human being </li></ul><ul><li>3- Competent vector </li></ul><ul><li>4- Multiple opportunities for contact between </li></ul><ul><li>the vector & human host. </li></ul>
  7. 8. <ul><li>Endemicity of malaria </li></ul><ul><li>- Endemicity is the amount & severity of malaria </li></ul><ul><li>in an area or community. </li></ul><ul><li>- Prevalence of malaria = to estimate the preval </li></ul><ul><li>of malaria a large No of people, sp infants and </li></ul><ul><li>children must be examined by: </li></ul><ul><li>1- Spleen rate : this is the proportion of </li></ul><ul><li>children (2-10 years) in a community </li></ul><ul><li>who have enlarged spleen: </li></ul><ul><li>- hypoendemic= spleen rate of 0-10% </li></ul><ul><li>- mesoendemic= spleen rate of 11-50% </li></ul><ul><li>- hyperendemic= spleen rate of over 50% </li></ul><ul><li>- holoendemic= spleen rate over 75% </li></ul>
  8. 9. <ul><li>2- Parasite rate = it is the proportion of persons in a given community who show parasites in the peripheral blood. </li></ul>
  9. 10. <ul><li>Immunity </li></ul><ul><li>1- Natural resistance depends on cellular factors </li></ul><ul><li>that prevent penetration & development of </li></ul><ul><li>parasites in the RBCs (G6PD def & HbC) and </li></ul><ul><li>the susceptibility of parasitized cells to </li></ul><ul><li>removal from circulation by lymphoid macrop </li></ul><ul><li>system (Hb AS, Hb F, Hb C), the later </li></ul><ul><li>protects against severe complicated malaria. </li></ul><ul><li>P.v can not invade RBCs with duffy blood </li></ul><ul><li>group </li></ul><ul><li>2- Acquired resistance is either passive transplacental which persists for 6/12 OR </li></ul>
  10. 11. <ul><li>active resistance which is sp & stage specific. </li></ul><ul><li>Humoral immunity deals with extracellular </li></ul><ul><li>parasites & cellular immunity deals with intracell </li></ul><ul><li>parasites. The Spleen traps & removes parasitized cells. </li></ul><ul><li>Pathogenesis </li></ul><ul><li>- Invasion of RBCs by malaria parasites is comm </li></ul><ul><li>to all sp. causing hemolysis, fever & splenome </li></ul><ul><li>- P.f is the only sp. that causes microvascular dis. With maturation of P.f the parasitized RBCs become spherical and knobs appear on the surface facilitating cytoadherance to </li></ul>
  11. 12. <ul><li>endoth cells of capillaries & post capillary venules of vital organs. Cytokines (TNF alpha) increases cytoadherance and microvascular obstruction, tissue anoxia and wide spread organ failure. </li></ul>
  12. 14. <ul><li>1- Fever is due to rupture of the schizonts </li></ul><ul><li>releasing toxic substances stimulating </li></ul><ul><li>macrophages to release endogenous pyrogen </li></ul><ul><li>raising temp. via the hypothalamus </li></ul><ul><li>2- Anaemia : rapidly developing anaemia is a </li></ul><ul><li>feature of P.f in children < 5y & pregn ladies </li></ul><ul><li>- hemolysis of parasitized & unparasitized </li></ul><ul><li>RBCs </li></ul><ul><li>- dyserythropoiesis - TNF alpha. </li></ul><ul><li>- haemodilution from sequestration of RBCs </li></ul><ul><li>in the spleen </li></ul><ul><li>- depletion of folate stores </li></ul>
  13. 15. <ul><li>3- Hypoglycemia :- related to the degree of </li></ul><ul><li>parasitaemia </li></ul><ul><li>- depletion of glycogen stores from low intake </li></ul><ul><li>- Increased Glucose consumption by the large </li></ul><ul><li>numbers of parasites. </li></ul><ul><li>- Hypoglycemic effect of TNF </li></ul><ul><li>- Quinine therapy & release of insulin </li></ul><ul><li>- Suppression of gluconeogenesis </li></ul><ul><li>4- Black water fever wz severe intravas hemolys </li></ul><ul><li>causing anaemia, Hb uria & renal failure </li></ul><ul><li>5- Immune thrombocytopenia & coagulopathy </li></ul>
  14. 16. <ul><li>6- Liver :- congested & enlarged with centrilobular necrosis in severe cases </li></ul><ul><li>7- Jaundice : either hemolytic or hepato cellular. </li></ul><ul><li>Hepato renal syndrome can occur. </li></ul><ul><li>8- Spleen : there is R/E hyperplasia with congestion, hage & thrombosis. Spleen is tender & may rupture. Hypersplenism. </li></ul><ul><li>9- Kidneys : Ischemic pre renal failure may occur </li></ul><ul><li>as well as immune complex nephritis </li></ul><ul><li>10- CNS : congested meningeal & cerebral capill </li></ul><ul><li>with parasitized RBCs with ring hage & mild reversible peri vascular inflammation. </li></ul>
  15. 17. <ul><li>11- Lungs : pulm edema </li></ul><ul><li>12- GIT : micro vascular dis causes mucosal </li></ul><ul><li>edema, hage & ulceration causing D & V </li></ul><ul><li>13- Adrenals : congestion & hage </li></ul><ul><li>14- Placenta : may be heavily parasitized sp. In </li></ul><ul><li>PG & may cause abortion & low birth Wt. </li></ul>
  16. 18. <ul><li>Uncomplicated malaria </li></ul><ul><li>Case definition : </li></ul><ul><li>1- Suspected malaria : Malaria is suspected when </li></ul><ul><li>a pat presents with fever (or history of fever </li></ul><ul><li>in za last 24 hours) and other S & S suggestive </li></ul><ul><li>of malaria after exclusion of other common </li></ul><ul><li>causes of fever in the area. </li></ul><ul><li>2- Confirmed malaria : Malaria is confirmed by </li></ul><ul><li>demonstration of asexual forms of za parasite </li></ul><ul><li>in za thick or thin peri BF or by rapid diagnost </li></ul><ul><li>test in the presence of fever </li></ul>
  17. 19. <ul><li>* When malaria is suspected & there is no </li></ul><ul><li>facilities for lab. diagnosis., assume that the pat has malaria when there is no other </li></ul><ul><li>obvious cause for za fever. </li></ul><ul><li>* Incubation period is 9—14 days in P.f </li></ul><ul><li>* Periodic fever is the hallmark of malaria and </li></ul><ul><li>coincides with rupture of RBCs & release of </li></ul><ul><li>new merozoites. </li></ul><ul><li>- Tertian wz P.v & P.o </li></ul><ul><li>- Quartan wz P.m </li></ul><ul><li>- Contin. wz irregular intermittent spikes </li></ul><ul><li>wz P.f, sometimes quotidian or sub tertian </li></ul>
  18. 20. <ul><li>* Paroxysms : </li></ul><ul><li>- Cold stage —15 min to hours </li></ul><ul><li>- Hot stage –2—6 hours </li></ul><ul><li>- Sweating stage —2—4 hours </li></ul><ul><li>* Anaemia & splenomegaly are other signs </li></ul><ul><li>* Herpes labialis is common </li></ul><ul><li>* Natural history of falciparum malaria varies </li></ul><ul><li>from rapidly fatal in the non immune to no </li></ul><ul><li>symptom in semi immune even with significa </li></ul><ul><li>parasitaemia. In non immune hyperparasit </li></ul><ul><li>with double infection (>5%) may lead to fatal </li></ul><ul><li>outcome in za absence of skilled management. </li></ul>
  19. 21. <ul><li>Lab diagnosis of malaria </li></ul><ul><li>1- Thick BF stained with Giemsa is examined </li></ul><ul><li>microscopically for: </li></ul><ul><li>- presence of infection </li></ul><ul><li>- Stage of parasite </li></ul><ul><li>- parasite count </li></ul><ul><li>+ 1—10 parasites/ 100 fields </li></ul><ul><li>++ 11—100 parasites/ 100 fields </li></ul><ul><li>+++ 1—10 parasites/ one field </li></ul><ul><li>++++ 11—100 parasites/ one field * Thin BF is used where sp other than P.f </li></ul><ul><li>coexist </li></ul>
  20. 23. <ul><li>2- Rapid diagnostic tests e.g. ICT. This is not </li></ul><ul><li>good in areas of high transmission where </li></ul><ul><li>asymptomatic parasitaemia & antigenaemia </li></ul><ul><li>is common. High cost but can be used by </li></ul><ul><li>unskilled personale , used in emergency and epidemic situations & where the cost of malaria TR is high to avoid unnecessary use of drugs. </li></ul><ul><li>Other investigations include: CBC, urine exam </li></ul><ul><li>BUN & E, blood sugar & serum bilirubin. </li></ul>
  21. 24. <ul><li>Management of uncomplicated malaria </li></ul><ul><li>1-1 st line TR :- Artsunate + sulfadoxine- pyremeth </li></ul><ul><li>- Artsunate (AS)= tabs of 50, 100 & 200 mg </li></ul><ul><li>SE = transient rise in transaminases & transien </li></ul><ul><li>reduction in reticulocytes </li></ul><ul><li>- Sulfadoxine- pyremethamine (SP)= fixed dose </li></ul><ul><li>schozonticidal combination against P.f </li></ul><ul><li>SP= 500 mg sulfadoxine + 25 mg pyremeth </li></ul><ul><li>in tab & injection forms. </li></ul><ul><li>SE = GIT, visual disturbance & cutaneous </li></ul><ul><li>reactions </li></ul>
  22. 25. <ul><li>* Dose regimens :- </li></ul><ul><li>- 1 st day= 4 mg/ kg BW AS + 25 mg/kg BW </li></ul><ul><li>sulfadoxine + 1.25 mg/kg BW pyremeth </li></ul><ul><li>- 2 nd day= 4 mg/ kg BW AS 24 h after 1 st dose </li></ul><ul><li>- 3 rd day= 4 mg/ kg BW AS 24 h after 2 nd dose </li></ul><ul><li>* TR failure is not always due to parasite resist? </li></ul><ul><li>If BF or RDT is +ve go to: </li></ul><ul><li>2- 2 nd line TR : Artemethe r (ARM) 20 mg- lumef </li></ul><ul><li>antrine (LF) 120 mg fixed dose comb. wz high </li></ul><ul><li>clinical & parasitological cure rate & rapid gametocyte clearance </li></ul>
  23. 26. <ul><li>SE = GIT, dizziness, fatigue, palpitation, headache skin rash, arthralgia,& myalgia. No serious cardiotoxicity </li></ul><ul><li>** Dose regimens : 4 tabs 1 st , repeated after 8h </li></ul><ul><li>then 4 tabs M & E 2 nd & 3 rd day, better taken </li></ul><ul><li>with fatty meal or milk. </li></ul><ul><li>3- 3 rd line TR : Quinine (Q) dihydroCL, Q CL or </li></ul><ul><li>Q SO4 used if no response ARM/ LF (lab+ve) </li></ul><ul><li>** Dose regimens : Oral= 10mg/kg 8 hrly x 7 D </li></ul><ul><li>- Injectable Q diluted IM or IV infusion 10mg/ </li></ul><ul><li>kg & shift to oral as soon as possible </li></ul>
  24. 27. <ul><li>Severe malaria ( SM) </li></ul><ul><li>- SM is defined as malaria due to P.f infection </li></ul><ul><li>sufficiently serious to be an immediate threat to </li></ul><ul><li>life. It is med emergency & require hospitalizati </li></ul><ul><li>- A pat is regarded as having severe malaria if </li></ul><ul><li>he or she has one or more of the following: </li></ul><ul><li>1- Impaired level of consciousness (cerebral mal </li></ul><ul><li>2- Resp distress (acidotic breathing) </li></ul><ul><li>3- Repetitive convulsions </li></ul><ul><li>4-Circulatory collapse </li></ul><ul><li>5- Pulm edema </li></ul><ul><li>6- Abn bleeding (DIC) </li></ul>
  25. 28. <ul><li>7- Jaundice </li></ul><ul><li>8- Hb uria </li></ul><ul><li>9- Prostration </li></ul><ul><li>10- Severe anaemia (Hb < 5gm/dl) </li></ul><ul><li>11- Hypoglycemia ( BS < 40mg/dl) </li></ul><ul><li>12- Acidosis </li></ul><ul><li>13- Hyperlactinaemia ( lactic acidosis) </li></ul><ul><li>14- Hyperparasitaemia ( >5% RBCs wz ring </li></ul><ul><li>stage) </li></ul><ul><li>15- Renal impairment </li></ul><ul><li>16- Electrolyte imbalance (hyponatraemia) </li></ul><ul><li>*** TSS is a chronic complication of malaria </li></ul>
  26. 29. <ul><li>Differential diagnosis of malaria </li></ul><ul><li>- Fever : infections ( viral, bacterial, protozoal) </li></ul><ul><li>- Rigors : UTI, septicemia, gall stones & cholecy </li></ul><ul><li>pneumonia, amoebic liver abs </li></ul><ul><li>- Cerebral malaria : meningitis, stroke, encephalit </li></ul><ul><li>metabolic in comatosed pats, </li></ul><ul><li>heat stroke </li></ul><ul><li>- Other causes of anaemia & splenomegaly </li></ul><ul><li>e.g typhoid, brucellosis </li></ul>
  27. 30. <ul><li>1- General management of SM(8+8+4) </li></ul><ul><li>* * Immediate measures : </li></ul><ul><li>1- Start resuscitation- ABC </li></ul><ul><li>2- IV line </li></ul><ul><li>3- Thick BF for immediate parasite count </li></ul><ul><li>4- Assess degree of dehydration, fluid requirem </li></ul><ul><li>and correct accordingly </li></ul><ul><li>5- Control fever if axillary temp 38.5 or above </li></ul><ul><li>by tepid sponge & fanning, paracetamol </li></ul><ul><li>15mg/kg 4—6 hourly </li></ul><ul><li>6- Control convulsion by diazepam. Correct hypogly 7- Detect & TR hypoglycemia which can recur specially in pregnant women & children </li></ul>
  28. 31. <ul><li>Give 1 ml/kg of 50% dextrose IV diluted in </li></ul><ul><li>equal volume of NS over 3-5 min. followed by </li></ul><ul><li>10% dextrose infusion </li></ul><ul><li>8- Start Q IV or ARM IM. Q IM or AS supposit </li></ul><ul><li>can do the job. </li></ul><ul><li>** Look & deal with following complications : </li></ul><ul><li>1- Shock, algid malaria: if SBP < 80mmHg </li></ul><ul><li>suspect septicemia & take blood samples for </li></ul><ul><li>cultures. Give parentral broad spectrum </li></ul><ul><li>antibiotics, saline infusion & O2 </li></ul><ul><li>2- Consider the need for BT: transfuse if there </li></ul><ul><li>is cardiopulm symptoms, PCV <20% or Hb<5 </li></ul>
  29. 32. <ul><li>3- Metabolic acidosis: exclude & TR hypoglycem </li></ul><ul><li>hypovolaemia & gm –ve septicemia. </li></ul><ul><li>4- Spontaneous bleeding & coagulopathy: fresh </li></ul><ul><li>screened whole BT or clotting factors, Vit K </li></ul><ul><li>10mg IV daily for adults </li></ul><ul><li>5- Acute renal failure: exclude dehydr, maintain </li></ul><ul><li>strict fluid balance. Dialysis if indicated </li></ul><ul><li>6- Black- water fever (malarial Hb uria): suitable </li></ul><ul><li>antimalarial & screened fresh BT </li></ul><ul><li>7- Acute pulm edema: prevent by avoiding </li></ul><ul><li>overload. IV frusemide & O2 8- Exclude common infections that mimic malaria </li></ul><ul><li>e.g. WBC, L/P & CXR </li></ul>
  30. 33. <ul><li>** Monitor the patient : </li></ul><ul><li>1- level of consciousness by Glasgow scale 6 hrly to </li></ul><ul><li>assess the progress until the pat regains </li></ul><ul><li>full consciousness </li></ul><ul><li>2- Fluid input/ output: detect dehydr & TR but avoid </li></ul><ul><li>overload e.g pulm edema </li></ul><ul><li>3- Monitor vital signs every 6 hrs to detect </li></ul><ul><li>compl of SM </li></ul><ul><li>4- level of parasitaemia: monitor parasite count </li></ul><ul><li>daily to monitor therapeutic effect </li></ul>
  31. 34. <ul><li>2- Specific treatment of SM </li></ul><ul><li>** Pre referral TR : Q IM or AS suppositories </li></ul><ul><li>10mg/kg rectal caps. Then refer to hospital </li></ul><ul><li>** Hospital TR: </li></ul><ul><li>1- Q IV infusion or IM if IV is not feasible & shift to oral as soon as possible. Total of 10mg/kg 8 hrly for 7 days </li></ul><ul><li>2- Q for 3 days & shift to 1 st line therapy if the </li></ul><ul><li>patient can take oral medication & can not tolerate oral Q. </li></ul><ul><li>SE = N, V & tinnitus. Over dose cause HA, dizzi, </li></ul><ul><li>CNS dist & delerium, hypoglycemia, hypotn </li></ul>
  32. 35. <ul><li>3- ARM injections ( 40mg & 80mg/ml) as </li></ul><ul><li>monotherapy should only be used for SM </li></ul><ul><li>- 1.6 mg/kg initially, repeated after 12 hrs </li></ul><ul><li>and then daily for 6 days (total of 8 amp) </li></ul><ul><li>- 1.6 mg/kg initially, repeated after 12 hrs </li></ul><ul><li>and then daily in za 2 nd & 3 rd day (4 amp) </li></ul><ul><li>followed by the 1 st line TR if the pat can </li></ul><ul><li>take orally. </li></ul><ul><li>- SE of ARM are mild= HA, abd pain, vomiting </li></ul><ul><li>itching, non specific ST changes & 1 st </li></ul><ul><li>degree A/V block. </li></ul>
  33. 36. <ul><li>Malaria in pregnancy (MIP) </li></ul><ul><li>1-The manifestation of malaria in preg , specially </li></ul><ul><li>in the 2 nd half, include: </li></ul><ul><li>- fever - anaemia </li></ul><ul><li>- splenomegaly - acute pulm edema </li></ul><ul><li>- hypoglycemia - 2ndry infections </li></ul><ul><li>2- Management of MIP : TR malaria & compl, </li></ul><ul><li>manage labour </li></ul><ul><li>- 1 st trimester = oral Q is safe 10mg/kgx3x7 </li></ul><ul><li>- 2 nd & 3 rd trimester = oral Q for 7 days OR </li></ul><ul><li>oral Q for 3 days followed by SP in full dose </li></ul><ul><li>OR use 1 st line TR </li></ul>
  34. 37. <ul><li>3- Management of SM during preg : </li></ul><ul><li>- Q 10mg/kg x3x7 days through out preg </li></ul><ul><li>- Start wz IV infusion or IM & shift to oral OR </li></ul><ul><li>- Start wz Q IV or IM for at least for 3 days OR </li></ul><ul><li>then shift to 1 st line TR in 2 nd & 3 rd trim OR </li></ul><ul><li>- ARM injections for 7 days </li></ul><ul><li>- Management of pulm edema, hypoglycemi </li></ul><ul><li>anaemia wz packed cell transfusion, renal F </li></ul><ul><li>and septicaemic shock or algid malaria by </li></ul><ul><li>3 rd generation cephalosporin, monitoring of </li></ul><ul><li>vital signs & fluids if required (SBP< 90) </li></ul>
  35. 38. <ul><li>4- Intermittent preventive TR (IPT): </li></ul><ul><li>- recommended only in high transmission </li></ul><ul><li>areas </li></ul><ul><li>- SP= 1 st dose in za 1 st ANC visit after quickening (16-20W) </li></ul><ul><li>- 2 nd dose 4W later </li></ul>
  36. 39. <ul><li>TR of Vivax malaria </li></ul><ul><li>- malaria other than P.f constitute 5—15% in </li></ul><ul><li>Sudan, mainly in eastern borders. Death is </li></ul><ul><li>rare & relapse expected wz P.v & Po. </li></ul><ul><li>- Still sensitive to CQ & susceptible to ARM/LF </li></ul><ul><li>- Primaquine used following TR of asexual forms </li></ul><ul><li>to clear exsoerythrocytic phase 15mg/d x14 d. </li></ul><ul><li>CI in preg, during lactation & children < 1year </li></ul>
  37. 40. <ul><li>Malaria prophylaxis & prevention </li></ul><ul><li>- The following are at higher risk for malaria: </li></ul><ul><li>1- travelers from malaria free areas </li></ul><ul><li>2- preg women, sp primigravida </li></ul><ul><li>3- SS dis </li></ul><ul><li>4- splenectomized individuals </li></ul><ul><li>5- children on steroids & immunosupp drugs </li></ul><ul><li>6- expatriates & sudanese returning from </li></ul><ul><li>non malarious areas </li></ul><ul><li>- Mefloquine 250mg weekly, starting one week </li></ul><ul><li>before entering the area & for 4W after </li></ul><ul><li>leaving za area. </li></ul>
  38. 41. <ul><li>Mefloquine not recommended in children < 3/12 </li></ul><ul><li>- atovaquine 250mg + proguanil 100mg begin </li></ul><ul><li>one day before entering the area & for 7 days </li></ul><ul><li>after leaving the area in those can not take </li></ul><ul><li>Mefloquine. </li></ul>
  39. 42. <ul><li>Tropical splenomegaly (TSS) </li></ul><ul><li>- Results from abn immunological response to </li></ul><ul><li>malaria </li></ul><ul><li>- Occurs in malaria endemic areas in the </li></ul><ul><li>indigenous inhabitants. Parasites not present </li></ul><ul><li>- There is high malarial Ab titre wz over- produc </li></ul><ul><li>of IgM & reduced C3 </li></ul><ul><li>- Massive splenomegaly >10cm which is firm </li></ul><ul><li>- Hepatic sinusoidal dilatation, infilt wz lymphocy </li></ul><ul><li>and Kupffer cell hyperplasia </li></ul><ul><li>- Pancytopeni a with normocytic normochromic </li></ul><ul><li>anaemia & reticulocytosis </li></ul>
  40. 43. <ul><li>- The condition is reversible </li></ul><ul><li>- Increased susceptibility to infection & there is </li></ul><ul><li>wasting in advanced cases </li></ul><ul><li>- Criteria for diagn of TSS : exclusion of other </li></ul><ul><li>causes of massive splenomegaly, immunity to </li></ul><ul><li>malaria, raised IgM, hepatic sinusoidal </li></ul><ul><li>lymphocytosis & IgM on immunofl & the </li></ul><ul><li>response to anti malarial prophylaxis </li></ul><ul><li>- TR for symptomatic pats with anaemia & large </li></ul><ul><li>spleen- -- Chemoprophylaxis + F acid </li></ul><ul><li>Splenectomy wz permanent malaria chemoprophylaxis in those who fail to respond. </li></ul>

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