EVERYTHING YOU NEED TO KNOW ABOUT THE MOST COMMON, YET MOST FATAL TROPICAL DISEASE, MALARIA

1. MALARIA
BY DR.BLEWUSI

2. Commonest
signs/symptoms
 Illness usually starts with fever and vomiting
 Commonest complications include coma(Cerebral
malaria), altered level of consciuosness, inability to sit
uo or drink(prostration, convulsions, severe anemia,
respiratory distress due to acidosis and hypoglycemia

3. Examination
 Make a rapid assessment, check for neck stiffness and rash to r/o
meningitis
 MAIN FEATURES INDICATIVE OF SEVERE MALARIA INCLUDE:
 1.Generalized multiple convulsion(>2 episodes in 24hours)
 2.Impaired consciousness, including unarousable coma.
 3. Generalized weakness(prostration)/lethargy(child unable to walk or
sit up without assistance.
 4.Deep laboured breathing and respiratory distress(acidotic breathing)
 5.Pulmonary oedema(or radiologic evidence)
 6.Abnormal bleeding
 7.Clinical jaundice plus evidence of other vital organ dysfunction
 8.Severe pallor
 9.Circulatory collapse or shock with systolic BP<50mmhg
 10.Haemoglobinuria
 11.Profuse repeated vomiting/ inability to tolerate fluids

4. LABFINDINGS
 1.Hypoglycaemia(<2.5 mmol/L)
 2.Hyperpasitaemia >500 000/ul
 3.Severe anaemia HB<5g/dl
 4.High serum creatinine >265umol/l
 5.Lumbar puncture to exclude bacterial meningitis
 If severe malaria is suspected and initial blood smer is-
, perform a rapid diagnostic test, if test is +, treat for
severe malaria, but continue to look for other causes
 For any child less than 6 months with RDT +

5. TREATMENT
 EMERGENCY MEASURES
 If child is unconscious, minimize the risk of aspiration
pneumonia by inserting an NG tube and removing gastric
contents by suctioning. Keep airway patent and keep in
recovery position
 Check for hypoglycemia and coreect if present
 Treat convulsions with rectal diazepam but don’t give
prophylactic anticonvulsants
 Start treatment with effective antimalarials
 If hyperpyrexia present, correct with ibuprofen or Pmol
to keep temperature below 39 degrees celcius
 Expediate treatment for dehydration and severe anaemia
 Institute regular observation of vital and neurological
signs

6. CONTRAINDICATIONS
TOLP
 1.Signs of raised intracranial pressure(anisocoria, rigid posture or
paralysis, in any limbs or trunk, irregular breathing)
 2.Skin infection in the area through which the needle will pass
 3.GCS</= 8
 4.Deteriorating GCS
 5.Had a seizure which lasted more than 10mins and still has a
GCS</=12
 6.Abnormal breathing pattern
 7.Abnormal doll’s eye response
 8.Abnormal posture
 9.Shock. 10. Bradycardia. 11.HPT (>95th percentile for age)
 12.Bradycardia(HR <60) 13.Clinical evidence of systemic meningococal
disease
 Pupilary reaction to light impaired or lost.
 Signs of raised ICP

7. Differentials
duringLP
 BACTERIAL MENINGITIS- 1.PMN 2.high protein 3.
low sugar gram stain
 ASEPTIC MENINGITIS- 1.Few lymphocytes 2.Normal
proteins 3.Normal sugar
 VIRAL ENCEPHALITIS- 1.Lymphocytic 2.Normal
sugar, 3.Normal to slightly raised protein
 TUBERCULOSIS MENINGITIS- 1.Opalescent, cob
web 2.Lymphocytic 3.High protein, 4.low sugar

8. TREATMENT
 If confirmation with RDT or blood smear is likely to take more than an hour, start
antimalarial treatment.
 Parenteral artesunate is the treatment of choice for severe Falciparum malaria. Alt if not
available include parenteral artemeter and quinine
 Parenteral medications should be given for a minimum of 24hours even if child can
tolerate oral medications, switch to orals after 24 hours if child can tolerate/ >24 hours if
cant
 ARTESUNATE:2.4mg/kg iv/im on admission then at 12 hours, 24 hours then daily untill
can tolerate orals
 QUININE: loading dose of 20ml/kg in 10ml/kg of IV fluid over 2-4 hours then 8hours after
the start of the loading dose, give 10ml/kg over 2hours then repeat every 8 hours till child
can tolerate orals.
 Infusion rate should not excede 5mg/kg per of quinine dihydrochloride salt.
 ARTEMETHER:Give artemeter at 3.2mg/kg IM on admission and 1.6mg/kg daily until
child can tolerate orals.
 After at least 24 hours of Parenteral antimalarials, switch to full course artemisinin based
combination eg:
 A.artemether-Lumefantrine
 B.artesunate plus amodiaquine
 C.Artesunate plus sulfadoxine-pyrimethamine
 D.Dihydroartemisinin plus piperaquine

9. TREATMENT
 Choice of drug routinely depends on if diagnosis is severe
or uncomplicated malaria
 In Ghana for uncomplicated malaria, 1st line of treatment
is an arthemther based combination, especially
arthemeter Lumefantrine
 Please take not that the time of taking medication is very
important if treatment will be achieved or not.
 After the first dose of artemether Lumefantrine, the
second dose is taken after 8 hours the same day, the next
day the 3rd dose is taken at the same time as the 1st and
the 4th dose taken 12 hours after the 3rd dose, 5th and
6th dose is taken at the same time as the 3rd and 4th.
 For example, if a patient takes the first dose at 1pm,
second dose will be at 9pm, 3rd dose will be at 1pm, 4th at
1 am 5th at 1pm and 6th at 1am

10. TREATMENT
DOSAGE OF
ARTEMETER(20mg)/LUMEFANTRINE(120mg) BY AGE
<6months---------not recommended
6months-3 years- 20/120mg
3years- 8 years 40/240mg
8years-12years 60/360mg
>12years- 80/480mg

11. CLASSIFICATION
DRUG GROUP EXAMPLE
Anti-folate combinations Dapsone-pyrimethamine
Sulfadoxine-pyrimethamine
Artemisinin derivatives Artesunate
Artemether
Dihydroartemisinin
Hydroxynaphthalenes Atovaquone-proguanil
Quinolone derivatives Quinine, Chloroquine
Amodiaquine,Piperaquine
Lumefantrinne, Mefloquine
Tafenoquine
Antibiotics Clindamycin
Doxycyclin

12. SUPPORTIVE
CARE
 Meticulous nursing care especially in unconcious
patients
 Daily fluid requirement and monitor fluid status with a
strict fluid, input and output chat
 If child unable to feed for 1-2 days, pass an NG tube
and give oral food, which is more preferable to IV fluids
 Avoid harmful drugs eg corticosteroids, low molecular
mass dextrans and anti-inflamatory drugs
 Adequate hydration whiles ensuring child is not
overyhydrated
 PLEASE IF RDT IS NEGATIVE AND BLOODFILM
FOR MALARIA PARASITE IS ALSO NEGATIVE,
THINK OF ANOTHER CAUSE OF SYMPTOMS, AND
DO WELL TO RULE OUT TYPHOID FEVER