4. MalariaMalaria
Malaria affects 270 million people eachMalaria affects 270 million people each
year and has mortality rate of 1%year and has mortality rate of 1%
Malaria is primarily a disease of hot, humidMalaria is primarily a disease of hot, humid
countries.countries.
In humans, malaria is caused by fourIn humans, malaria is caused by four
species ofspecies of plasmodium, p. ovale, p. falciparum,plasmodium, p. ovale, p. falciparum,
p. vivax, p. marlariaep. vivax, p. marlariae
P. ovale has been reported predominantlyP. ovale has been reported predominantly
from east and west Africafrom east and west Africa
6. MalariaMalaria
P. vivax is the major species in temperate zoneP. vivax is the major species in temperate zone
whereas in tropics all forms of malaria are seenwhereas in tropics all forms of malaria are seen
Humans, the intermediate hosts, are infectedHumans, the intermediate hosts, are infected
following the bite of an infected femalefollowing the bite of an infected female
anopheles mosquito, the definitive hostanopheles mosquito, the definitive host
The parasite can be transmitted by bloodThe parasite can be transmitted by blood
transfusion, transplacentally and increasinglytransfusion, transplacentally and increasingly
between drug addicts who use improperlybetween drug addicts who use improperly
cleaned syringes.cleaned syringes.
7. MalariaMalaria
The introduction of sporozoites, theThe introduction of sporozoites, the
infective form of parasite, through the skininfective form of parasite, through the skin
by anopheles mosquito heralds theby anopheles mosquito heralds the
commencement of human cycle. Thecommencement of human cycle. The
following stages occurfollowing stages occur
Pre-erythrocytic shizogonyPre-erythrocytic shizogony
Erythrocytic shizognyErythrocytic shizogny
GametogonyGametogony
Exoerythrocytic shizognyExoerythrocytic shizogny
10. MalariaMalaria
When an anopheles mosquito ingestWhen an anopheles mosquito ingest
human blood containing gametocytes ithuman blood containing gametocytes it
marks the commencement of sexual cyclemarks the commencement of sexual cycle
in mosquitoin mosquito
The external incubation period varies fromThe external incubation period varies from
7-20 days7-20 days
11. ImmunityImmunity
May be natural or acquired
The presence of Hb S, glucose-6-phosphate
dehydrogenase deficiency, thalasaemia, and
pyruvate kinase deficiency offer resistance
against P. falciparum.
Splenectomized individuals are highly
susceptible to the malarial parasite
Infants are protected by transfer of maternal
IgG antibodies across the placenta
12. Clinical FeaturesClinical Features
Malarial febrile paroxysms typically have threeMalarial febrile paroxysms typically have three
stagesstages
TheThe “cold stage”“cold stage” is characterized by markedis characterized by marked
vasoconstriction and lasts from 30 minute 1 hour.vasoconstriction and lasts from 30 minute 1 hour.
The patient feels intensely cold and uncomfortable.The patient feels intensely cold and uncomfortable.
There is marked shivering. The temperature risesThere is marked shivering. The temperature rises
rapidly often to as high as 41rapidly often to as high as 41oo
CC
TheThe “hot stage”“hot stage” abruptly follows and lasts for 2-6abruptly follows and lasts for 2-6
hours. Patient feels intensely hothours. Patient feels intensely hot
TheThe “sweating stage”“sweating stage” then occurs, during which thethen occurs, during which the
bed clothes are drenched. The patient feels fatiguedbed clothes are drenched. The patient feels fatigued
and exhausted but otherwise well.and exhausted but otherwise well.
13. P. Vivax and P. ovaleP. Vivax and P. ovale
The fever occurs every other day whenThe fever occurs every other day when
establishedestablished
Usually mild infectionUsually mild infection
There are frequent relapses andThere are frequent relapses and
eradication of organism is difficulteradication of organism is difficult
14. P. MalariaeP. Malariae
Usually mild disease but tends to run aUsually mild disease but tends to run a
more chronic coursemore chronic course
Nephrotic syndrome is seen betweenNephrotic syndrome is seen between
the age of 4 and 5 yearsthe age of 4 and 5 years
15. P. FalciparumP. Falciparum
Is the most severe form of malariaIs the most severe form of malaria
(pernicious malaria)(pernicious malaria)
The prodrome tends to be severeThe prodrome tends to be severe
The fever follows no particular pattern andThe fever follows no particular pattern and
the characteristic cold, hot and sweatingthe characteristic cold, hot and sweating
stages are not prominentstages are not prominent
There is severe organ damage, chiefly inThere is severe organ damage, chiefly in
the kidneys, liver, brain and gastrointestinalthe kidneys, liver, brain and gastrointestinal
tracttract
16.
17. Cerebral MalariaCerebral Malaria
It is likely to occur when more thanIt is likely to occur when more than
2% of RBC are parasitized2% of RBC are parasitized
There is high grade fever, deteriorationThere is high grade fever, deterioration
in concious level, convulsion coma andin concious level, convulsion coma and
deathdeath
18. Black Water FeverBlack Water Fever
This rapidly progressive illness characterized byThis rapidly progressive illness characterized by
abrupt onset of fever, marked haemolysis,abrupt onset of fever, marked haemolysis,
haemoglobinuria, hyperbilirubinemia, vomitinghaemoglobinuria, hyperbilirubinemia, vomiting
circulatory collapse and acute renal failurecirculatory collapse and acute renal failure
Malarial parasite can not be detected inMalarial parasite can not be detected in
peripheral blood smear after the onset ofperipheral blood smear after the onset of
intravascular haemolysisintravascular haemolysis
Severe anaemiaSevere anaemia
DICDIC
19. Black Water FeverBlack Water Fever
Respiratory complications
Adult respiratory distress syndrome
Metabolic
Hypoglycemia, Metabolic acidosis
Gastrointestinal/ liver
Diarrhea, Jaundice, Splenetic rupture
Shock secondary to septicaemia
In pregnancy
Maternal death, Abortion, Still birth, low birth
weight
20. Tropical Splenomegaly SyndromeTropical Splenomegaly Syndrome
Seen in areas where malaria is hyperendemicSeen in areas where malaria is hyperendemic
There is massive splenomegalyThere is massive splenomegaly
Marked elevation of serum IgM levelMarked elevation of serum IgM level
IgM aggregates in kupffer cells in the liverIgM aggregates in kupffer cells in the liver
detected by immunofluorescencedetected by immunofluorescence
Splenomegaly and anaemia resolves over periodsSplenomegaly and anaemia resolves over periods
of months of continuous treatment withof months of continuous treatment with
proguanil 100mg/day along with folic acid.proguanil 100mg/day along with folic acid.
21. DiagnosisDiagnosis
Thick and thin blood film will demonstrateThick and thin blood film will demonstrate
malarial parasite 2-3 smear taken each daymalarial parasite 2-3 smear taken each day
for 3-4 day and found to be negative arefor 3-4 day and found to be negative are
necessarynecessary
Serological test includeSerological test include
i)i) Indirect immunoflorescence,Indirect immunoflorescence,
ii)ii) Indirect haemagglutinationIndirect haemagglutination
iii)iii) Gel diffusion techniquesGel diffusion techniques
22.
23.
24. TreatmentTreatment
Chemotherapy of acute attackChemotherapy of acute attack
Chloroquine is the drug of choiceChloroquine is the drug of choice
600 mg of the effective base600 mg of the effective base
followed by 300 mg base in 6 hrsfollowed by 300 mg base in 6 hrs
and then 150 mg base twice daily forand then 150 mg base twice daily for
two daystwo days
25. TreatmentTreatment
Infections with P. falciparum fromInfections with P. falciparum from
chloroquine-resistant area should bechloroquine-resistant area should be
treated with quinine dihydrochloride ortreated with quinine dihydrochloride or
sulphatesulphate
600 mg salt (10 mg/kg) 8 hourly until better600 mg salt (10 mg/kg) 8 hourly until better
and the blood is free of parasite (usually 3-5and the blood is free of parasite (usually 3-5
days)days)
This regimen should be followed by a singleThis regimen should be followed by a single
dose of sulphadoxin 1.5 gram conutined withdose of sulphadoxin 1.5 gram conutined with
pyramethamine 15 mg i.e. 3 tab of fansidarpyramethamine 15 mg i.e. 3 tab of fansidar
26. TreatmentTreatment
Alternative to quinine and fansidar areAlternative to quinine and fansidar are
melfoquine 20 mg/kg up to max of 1.5 g inmelfoquine 20 mg/kg up to max of 1.5 g in
two divided dose 8 hours apart. It maytwo divided dose 8 hours apart. It may
cause neuropsychiatric symptomscause neuropsychiatric symptoms
Halofantrine (Halfan) 500 mg every 6Halofantrine (Halfan) 500 mg every 6
hours for 3 doses prolonged GT, cardiachours for 3 doses prolonged GT, cardiac
arrythmia in susceptible individualarrythmia in susceptible individual
Artemesinin and derivatives (artemetter,Artemesinin and derivatives (artemetter,
artesunate) they are effective but have noartesunate) they are effective but have no
action on liver stageaction on liver stage
27. Management of complicatedManagement of complicated
P. falciparum malariaP. falciparum malaria
Patient with cerebral malaria, or otherPatient with cerebral malaria, or other
severe manifestations are medicalsevere manifestations are medical
emergenciesemergencies
Quinine is given as an intravenousQuinine is given as an intravenous
infusion over 4 hours. Dose is 10infusion over 4 hours. Dose is 10
mg/kg of quinine salt up to max ofmg/kg of quinine salt up to max of
700 mg-8 hourly until the patient is700 mg-8 hourly until the patient is
able to take the drug orallyable to take the drug orally
28. ChemoprophylaxisChemoprophylaxis
Choloroquine resistant patientsCholoroquine resistant patients
Chloroquine plusChloroquine plus
Proguanil orProguanil or
mafloquinemafloquine
Chloroquine resistance absentChloroquine resistance absent
Chloroquine orChloroquine or
ProguanilProguanil
41. Peripheral Smear Preparation
Peripheral smear examination for malarialPeripheral smear examination for malarial
parasite is the gold-standard in confirming theparasite is the gold-standard in confirming the
diagnosis of malaria. Thick and thin smearsdiagnosis of malaria. Thick and thin smears
prepared from the peripheral blood are used forprepared from the peripheral blood are used for
the purpose.the purpose.
42. STEP 1STEP 1
Hold the third finger of the left hand and clean it with swab
dipped in Savlon or dettol
43. Step 2Step 2
Prick the finger with needle or lancet and allow the
blood to ooze out.
44. Step 3Step 3
Take a clean glass slide. Take 3 drops of blood 1 cm from the
edge of the slide, take another drop of blood one cm from the
first drop of blood
45. Step 4Step 4
Take another clean slide with smooth edges
and use it as a spreader...
48. Thick FilmThick Film
The thick smear of correct thickness is the one through whichThe thick smear of correct thickness is the one through which
newsprint is barely visible.newsprint is barely visible.
It is dried for 30 minutes and not fixed with methanol.It is dried for 30 minutes and not fixed with methanol.
This allows the red blood cells to be hemolyzed and leukocytesThis allows the red blood cells to be hemolyzed and leukocytes
and any malaria parasites present will be the only detectableand any malaria parasites present will be the only detectable
elements.elements.
However, due to the hemolysis and slow drying, the plasmodiaHowever, due to the hemolysis and slow drying, the plasmodia
morphology can get distorted, making differentiation of speciesmorphology can get distorted, making differentiation of species
difficult.difficult.
Thick smears are therefore used to detect infection, and toThick smears are therefore used to detect infection, and to
estimate parasite concentration.estimate parasite concentration.
49. Thin FilmThin Film
Air dry the thin smear for 10 minutes.Air dry the thin smear for 10 minutes.
After drying, the thin smear should be fixed inAfter drying, the thin smear should be fixed in
methanol. This can be done by either dippingmethanol. This can be done by either dipping
the thin smear into methanol for 5 seconds orthe thin smear into methanol for 5 seconds or
by dabbing the thin smear with a methanol-by dabbing the thin smear with a methanol-
soaked cotton ball.soaked cotton ball.
While fixing the thin smear, all care should beWhile fixing the thin smear, all care should be
taken to avoid exposure of the thick smear totaken to avoid exposure of the thick smear to
methanol.methanol.