Malaria their types and management.

2. MALARIA
Dr.M Naeem Malik
Houseofficer
Dr Saba Noor

3. Outlines
● Introduction
● Classification
● Epidemiology
● Transmission
● Life cycle
● Pathophysiology
● Clinical Features
● Diagnosis
● Complications
● Management

4. INTRODUCTION
 MALARIA is a Commom acute or chronic infection,
caused by any one of the five species of plasmodium Parasite
and is Characterized by
 Recurrent high grade fever with
Rigors and chills.
 Splenomegaly
 Anemia

5. Classification
 There are five species
 Common species Rare species
 P.Falciparum (most virulent) ●P.Malariae
 P.vivax (most common) ●P.ovale
●P. knowlesi

6. Epidemiology
 Malaria is an important cause of global child deaths,
most of which occur due to P.falciparum.
 Malaria is endemic in Pakistan
 More common in Sindh and Baluchistan
 Geography : areas near water reservoirs
 Season : Warm
 Usual age :all age groups,more common in 6 months to
5 years

7. Transmission
●Malarial parasite is an oblique Intracellular protozoan
transmitted through bite of Arthropod borne female
Anopheles mosqito.
●Malaria can also be spread through direct exposure to
infected blood transfusion,or contamintaed needles.
●Congenital Malaria appears in young
infants born to a mother who carried
the infection during pregnancy .
●Most malarial deaths occur in infants
and young children.

8. LIFE CYCLE
Life cycle of the mosquito is completed in the human host
(asexual phase)And also in the mosquito vector (sexual phase)

9. Conti...
Life cycle
Two major phases
🔘Asexual Phase (Schizogony) in Humans
🔘Sexual Phase(sporogony) in Mosquitoes
🔘Asexual phase further divided into two phases
1.Exo-erythrocytic Phase:Mosquito bite-> Sporozoites enter into
human -> taken by liver cells -> in liver develop into schizonts ->
schizonts rupture -> Merozoites released in RBC’s.
Remember:
In plasmodium ovale & Vivax some schizonts remain in liver
called hypnozoite, causing relapses of malaria.

10. Conti..
2.Erythrocytic phase:Inside RBC's parasites again multiply
forming new Merozoites->released and infects further Cells
🔘Sexual Phase:It begins when mosquito ingest blood
containing male & female gametocytes.In mosquito’s stomach
microgamete penetrates the macrogamete generating
zygote.Zygote in turn become motile & elongated (Ookinates)
which invade the midgut wall of mosquito where they develop
into oocysts.
🔘Duration of cycle:
48 hours P.falciparum in P. ovale, P. Vivax
72hours in P.Malariae

11. Pathophysiology
●Symptoms of malaria appear only when RBCs rupture.
●Fever is the most remarkable Symptom when RBCs rupture and
merozoites are released in circulation. Production of tumor
necrosis factor or other cytokines are responsible for fever.
●Hypoglycemia is due to decreased glycogen stores, impaired
gluconeogenisis and increased glucose consumption by the
malarial parasite.

12. Conti...
●Spleenomegaly is important feature of malaria.RBCs infected with
plasmodium lose their deformability. There is increased trapping in
the spleenic cords causing enlargment of spleen.
●Anemia mainly due to RBCs hemolysis (greatest in P.falciparum due
to heavy parasitemia)
●Due to massive hemolysis there may be
●Hemoglobinuria
●Hyperkalemia
●Hyperbilirubinemia
●Hemoglobinemia.

13. Conti...
●Infected RBCs become rigid and sticky blocking the passage
through capillaries. Blood flow become sluggish as more and
more cells and debris accumulate causing local tissue
hypoxia.this phenomenon is responsible for complications of
falciparum Malaria e.g
●Cerebral malaria
●Pulmonary edema
●Renal failure
●intestinal malabsorption.

14. Clinical Features
●Clinical features are variable depending on the species
involved,patient’s age and immune status.
●Symptoms are more severe in P.falciparum.
●High grade Fever with rigors and chills
●Headach
●Fatigue
●Nausea
●Delirium
●Vomiting

15. Conti...
●This paroxysmas classically returns after 48-72hours depending
on plasmodium species.children usually not show the
characteristic fever pattern they usually have continous or
intermittent fever.
●Other finding include splenomegaly, jaundice,pallor due to
anemia.
●Malarial relapse may occur in case of P.vivax or P.Ovale.

17. DIAGNOSIS
●Clinically history and examination is very important for the
diagnosis of malaria
(Traid of Fever,Splenomegaly and anemia)
●The diagnosis of malaria is established by identification of
organisms on Giemsa-stained Smears of peripherial blood.
●Giemsa-stained consist of thick and thin smear
Thick smear done first for screening parasitemia
Thin smear done for identification of malarial species.

18. Conti....
RDT (Rapid Diagnostic Test) for Malaria
●WHO Recommended method.
●Malarial Antigen detection in blood
(immunochromatographic method)

19. COMPLICATIONS
●Anemia
●Jaundice
● Splenomegaly (more common
with repeated infections)
●Relapses (P. vivax) (due to exoerythrocytic
hepatic cycle.

20. Serious Complications of Falciparum Malaria
●Cerebral malaria
Hypoxia of brain due to vascular capillary obstruction by
parasitized RBCs
High fever,unconscious,Fits,neurological deficits
●Blackwater fever – Severe intravascular hemolysis,
Hemoglobinuria, renal failure
●Algid malaria – Hypotension, circulatory collapse, shock
● Hypoglycemia

21. Management of Malaria
Supportive care
●Antipyretics and Analgesics
paracetamol,ibruprofen,tap water sponging
●Hydration – oral / IV fluids
●Nutrition – smallfrequent oral / NG(tube)feed
●Blood transfusionfor Anemia

22. Choice of Anti-malarial drugs depends
upon •
●Age of patient
● Clinical presentation
● Infecting species – Vivax / Falciparum
●Local resistance pattern
●Adverse effects

23. Specific measures
●Anti-malarial treatment should be started immediately once
the diagnosis of malaria made. Delay in treatment may
adversely affect the prognosis especially in P.falciparum
malaria.A response to treatment is defined as a decrease daily
parasitemia.
●Artemether is given 3.2mg/kg by immediate intramuscular
injection, followed by 1.6 mg/kg daily for 3 days
●Chloroquine affects the erythrocytic parasites
only.Chloroquine is the drug of choice in chloroqine sensitive
Plasmodium. Chloroquine is given 10 mg base per kg
immediately, followed by 5mg/kg base at 6, 24 & 48 hours

24. Conti..
🔘If the parasite count does not drop rapidly (within 24-48
hours) or does not become negative within 4 days, it shows
chloroquine-resistant malaria and the patient is given a
different antimalarial regimen
● For chloroquine-resistant P. falciparum, Quinine
dihydrochloride 20 mg salt per kg is infused during 4 hours,
followed by maintenance of 10 mg salt per kg infused during
2-8 hours every 8 hours for 3 days.
●Parenterally administered artemether can be substituted for
quinine for treatment of severe malaria in children.

25. Conti....
🔘Patients from areas with chloroquine-resistant P. falciparum
who have mild infection, parasitemia less than 1%, no evidence
of complications, and no vomiting and who can take oral
medication can be given oral therapy with either oral
atovaquone-proguanil. oral artemether-lumefantrine, or oral
quinine plus doxycycline, tetracycline, or clindamycin.

27. PREVENTION
Personal protection
●Wear long clothes
●Mosquito nets
●Repellants
●Sprays
Community
●Destroy Mosquito breeding places
● Pesticides
● Drain stagnant water

28. Conti...
●Chemoprophylactic drugs are given once weekly,starting 1-2
weeks before going to endemic area,continuing throughtout the
stay,and ending 4 weeks after leaving the endemic area.
●Chloroquine weekly (chloroquine – sensitive areas) 5mg base /kg
●Mefloquine weekly (chloroquine – resistant areas)
4.6mg base/kg/ week
●Doxycycline is given in patients older than 8 years of age who
dont tolerate mefloquine.2mg/kg/day