Malaria is a vector-borne infectious disease caused by Plasmodium parasites and transmitted via the bites of infected Anopheles mosquitoes. There are five main species that cause malaria in humans, with P. falciparum being the most deadly. Symptoms include fever, chills, sweating and flu-like illness recurring in cycles. Severe malaria can cause complications like cerebral malaria, severe anemia, hypoglycemia and death if untreated. Diagnosis is by blood smear microscopy or rapid diagnostic tests, with treatment depending on severity and species but primarily involving artemisinin-based combination therapies or quinine for severe cases. Prevention focuses on mosquito control and use of insecticide-treated bed nets

1. Malaria
CLINICAL APPROACH
BY: Kpehe Jig Maimie, INTERN

2. INTRODUCTION
o A vector borne infectious disease caused by singe – celled
protozoan parasites of the genus Plasmodium
o Transmission
 via the bite of an infected female Anopheles Mosquitoes
 do not occur at Temp. < 160 C or > 330 C or
 Attitude > 2000 meters

3. ETIOLOGY

4. o Caused by a singe – celled protozoan parasites of the genus
Plasmodium
Namely:
a) Falciparum (Malignant | incubation 7~12 day )
b) Vivax (Tertian | incubation 13~15 day)
c) Malariae (Quartan | incubation - 24-30 day)
d) Ovale (Tertian | incubation 13~15 day)
e) Knowlesi (Quotidian | incubation 24hrs)
o Transmitted via the bite of an infected female Anopheles Mosquitoes

5. Affinity of Plasmodium Parasites
a) Malariae (Infect young Erythrocytes)
b) Ovale (Infect Old Erythrocytes)
c) Falciparum (Infects RBC of all ages)
- adhere to the endothelial lining of Blood vessels
- Causes Obstruction, Thrombosis & Local
Ischemias

6. Epidemiology
 P. Falciparum accounts for 90% of deaths
 P. Vivax is most widespread species; existing in both temperate
and Tropical Climate
 Affects over 40% of the world’s Population
 WHO, estimates 350 - 500 million cases of Malaria worldwide
 270 – 400 million caused by P. Falciparum
 Causes 7,500,000 – 2 million deaths annually

7. Types
 Severe Malaria
 Uncomplicated Malaria

8. Typical Attack
 Chill: Abrupt onset, shivering, pale face, cyanosis; lasting
for 10 min or 1~2hr.
 High fever: T rise to 40oC with malaise, myalgia, Cough
Nausea & Vomiting, Diarrhea, anorexia, Abdominal pain,
Headache
 Sweating: profuse sweating with restlessness
 Regular 48 hr. or 72 hr. Cycle

9. Severe Malaria (Clinical Features)
 Life threatening; caused mainly by P. falciparum
 Characterized by:
 Altered Mental Status
 Coma
 Prostration
 Convulsion
 Severe Anemia
 Respiratory Distress
 Hypoglycemia

10. Severe Malaria (Hx & P/E Findings)
History
► Fever, Confusion, Drowsiness, Altered consciousness, Generalized weakness,
Examination
► Impaired Consciousness,
► Generalized Weakness (Prostration)
► Deep Labored Breathing (acidotic respiration)
► Clinical Jaundice
► Severe Pallor
► Circulatory Collapse ( Systolic < 50 mmHg)
► Dark Urine (Hemoglobinuria)

11. Labs
► RDT & Microscopy (Malaria Smear)
► RBS & Electroytes
► Serum Creatinine
► Lumbar Puncture
► Widal
► Lumbar Puncture

12. Diagnostic Criteria – Severe Malaria
► Hyperparasitaemia (> 100 000 / uL)
► Hypoglycemia (bld glucose < 45mg/dl)
► Severe Anemia (EVF <15%, Hb < 5g/dl)
► Serum Creatinine (> 265 mmol/liter)
► High Blood lactate (> 5 mmol/liter)

13. Treatment (As per National Guidelines)
 Parenteral Artesunate (IM/IV) unless contraindicated
IV (preferred): 2.4mg/kg @ 0hr, 12hr, 24hrs.. Then QD x 2 days; then
Oral ACT x 3 days
 2nd Option: IM Artemeter 3.2mg/kg loading dose; 1.6 mg
(or ½ loading dose) QD x 2days.., then Oral ACT x 3 days
 3rd Option: Quinine Hydrochloride 10mg/kg, IV infusion in
5 – 10 ml/kg of glucose 5% to run over 4hrs. REPEAT Q8hr until patient
can tolerated oral Meds; Transition to oral Quinine 10mg/kg Q8hrs x 72hrs

14. Treatment cont’d
 Hypoglycemia / Coma - if glucose is <2.5mmol/l ( 45mg/dl) in
normally nourished child or 3mmol/l (55 mg/dl) in malnourished child;
give: D50% glucose Bolus @ (1-5ml/kg) ; if glucose test not available,
give 10% glucose bolus @ (5cc/kg)
 Convulsion : Secure airway; correct HYPOGLYCEMIA; Give DZP
0.5mg/kg rectally; + Diarrhea = IV/IM 0.3mg/kg slow bolus
 Shock: O2 ( < 1 yr: 0.5L/min; > 1 yr: 1L/min); Rehydration: IVF ( NS /RL)
Normally Nourished Child: 20mg/kg; repeat x 2 if not improving
Malnourished Child: 15mg/kg over 1hr; Repeat x 1 over 2hrs; if not improving
If no improvement, Treat presumptively for SEPTIC SHOCK (AMP & GENT)

15. Treatment cont’d
 Severe Anemia - if (HCT < 15%; Hb < 5g/dl); give 10 – 15ml/kg PRBC
or 20mg/kg whole Blood over 3 – 4 hrs; Supplement with FEFA x 14 days
Initiate O2 Therapy unless SPO2 = 95%
 Hyperpyrexia : give antipyretic ( Preferably PCM)
Uncomplicated Malaria
- Treat for 3 days with the recommended Artemisinin – Based
combination Therapy Options:
Artemeter – Lumefantrine; Artesunate Plus amodiaquine;
Artesunate plus Sulfadoxine, Artesunate; Sulfadoxine- pyrimethamine etc

16. Prevention
 Eliminate Mosquitoes breeding places
 Using Treated Bed nets
 Using clothing with sleeves and long trousers at night
 Use Mosquito repellents

17. Thank you
!

18. References
 Hospital Care for Children Guidelines, WHO;
 Performance Based Financing( MOH), RL
 Uptodate.com