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Malaria
- 1. What Is malaria? • A mosquito-borne infectious disease caused by Protozoan parasites of the genus Plasmodium
- 2. What Is malaria? • Transmitted only by Anopheles Mosquitoes (>60 species!) Seattle Biomedical Research Institute
- 3. Plasmodium species which infect humans Plasmodium vivax Plasmodium ovale Plasmodium falciparum Plasmodium malariae Plasmodium knowlesi
- 4. Components of the Malaria Life Cycle Sporogonic cycle Infective Period Mosquito bites uninfected person Mosquito Vector Parasites visible Human Host Mosquito bites gametocytemic Prepatent Period Symptom onset person Recovery Incubation Period Clinical Illness
- 5. Malaria Life Sporogony Cycle Oocyst Life Cycle Sporozoites Mosquito Salivary Zygote Gland Hypnozoites Exo- (for P. vivax and P. ovale) erythrocytic (hepatic) cycle Gametocytes Erythrocytic Cycle Schizogony
- 7. Acute Symptoms • Classical features include cyclic symptoms – Cold stage: chills and shaking – Hot stage: fever, headache, vomiting, seizures in children – Sweating stage: weakness – Feel well for period of time, then cycle repeats itself www.uhhg.org/mcrh/resources/video/malariappt.pdf
- 8. Clinical presentation • Early symptoms – Headache – Malaise – Fatigue – Nausea – Muscular pains – Slight diarrhea – Slight fever, usually not intermittent • Could mistake for influenza or gastrointestinal infection
- 9. Clinical presentation • Acute febrile illness, may have periodic febrile paroxysms every 48 – 72 hours with • Afebrile asymptomatic intervals • Tendency to recrudesce or relapse over months to years • Anemia, thrombocytopenia, jaundice, hepatosplenomegaly, respiratory distress syndrome, renal dysfunction, hypoglycemia, mental status changes, tropical splenomegaly syndrome
- 10. Malarial Paroxysm • Can get prodrome 2-3 days before – Malaise, fever,fatigue, muscle pains, nausea, anorexia – Can mistake for influenza or gastrointestinal infection – Slight fever may worsen just prior to paroxysm • Paroxysm – Cold stage - rigors – Hot stage – Max temp can reach 40-41o C, splenomegaly easily palpable – Sweating stage – Lasts 8-12 hours, start between midnight and midday
- 11. Malarial Paroxysm • Periodicity – Days 1 and 3 for P.v., P.o., (and P.f.) - tertian – Usually persistent fever or daily paroxyms for P.f. – Days 1 and 4 for P.m. - quartian
- 12. Each disease has a distinct course “Tertian Malaria” (P.falciparum, P.ovale and fever occurs every third da “Quartan Malaria” (P. malariae) fever occurs every fourth www.uhhg.org/mcrh/resources/video/malariappt.pdf
- 13. Each disease also has a distinct geographical distribution www.columbia.edu/itc/hs/medical/pathophys/parasitology/2006/PAR-05Color .pdf
- 14. Each disease also has a distinct geographical distribution www.columbia.edu/itc/hs/medical/pathophys/parasitology/2006/PAR-05Color .pdf
- 15. DIAGNOSIS Gold standard: Multiple thick and thin smears
- 16. Other tests Generally the complete blood counts and platelets counts are of little benefit in the diagnosis but aid in assessing the severity and complications of the ongoing infection. PfHRP2 dipstick or card test: monoclonal ab captures the parasite antigens. Only for falciparum malaria. LDH dipstick or card test
- 18. Drugs used to treat Malaria-First group • CHQ, Amiodaquine • Quinine, Quinidine • Mefloquine, Halofantrine • Lumefantrine
- 19. Drugs used to treat Malaria-others • Clindamycin • Azithromycin • Proguanil • Dapsone • Primaquine
- 20. How to select antimalarials Type of malaria – vivax or falciparum? Sensitive or resistant Associated renal or liver damage Associated metabolic-electrolyte imbalances Pregnancy, weight Drug reactions Oral therapy possible?
- 21. Intravenous anti-malarial therapy- Indications Presence of vomiting Inability to start oral therapy may also be due to altered mental alertness and seizures. Patients who are intubated and on ventillators. Those who are critically ill.
- 22. Intra-venous therapy Chloroquine: intravenous 10 mg/kg max 600mg over 6-8 hrs followed by 15mg/kg max 900mg over next 24 hrs as slow infusion. Quinine : intravenous 20mg/kg over 4 hrs; then 10mg/kg(max 600mg)three times a day.
- 23. Intra-venous therapy-severe f.malaria Artesunate 2.4mg/kg stat; followed by 2.4mg/kg at 12 hrs, 24hrs and then daily. OR Artemether 3.2mg/kg stat im; then 1.6mg/kg od im. PLUS Add quinine 20mg salt/kg over 4 hrs; followed by 10mg/kg over 2-8 hrs slow infusion thrice a day. PLUS Doxy 100mg bd / tetra 250mg (4mg/kg) qds
- 24. Multidrug resistant malaria- 2nd line Doxy 100mg bd (3mg/kg x 7 days) Artesunate 2mg/kg od or quinine 10mg/kg tds PLUS 1 drug of the following: Tetra 250mg qds (4mg/kg qid x 7 days) Clindamycin 10mg/kg bd x 7 days or atovoquone-proguanil 20/8 mg/kg od x 3 days
- 25. Other supportive therapy • Maintain acid-base balance • Maintain blood sugar • Add folvite for hemolysis • Blood transfusions • Exchange transfusion
- 26. chemoprophylaxis • Chloroquine 5mg base/kg (max 300 mg) once a week. Begin 1-2 weeks before travel, during stay and continue till 4 weeks after returning from malarious area. • Mefloquine 5mg salt/kg (max 250 mg) once a week. Regime same as above. • Atovoquone/proguanil (250/100mg) 1 tab for travel to resistant malarious area beginning 1-2 days before travel and taken daily during stay and ctd till 1 week after return from malarious area.