This document provides an outline and overview of malaria management. It begins with an introduction describing how malaria is caused by Plasmodium parasites transmitted via mosquitos. It then covers the epidemiology, noting high-risk groups and prevalence in Africa. Etiology describes the 5 Plasmodium species infecting humans. Pathophysiology explains genetic resistance factors. Clinical features are described for both uncomplicated and complicated malaria. Diagnosis, treatment, complications, prognosis and prevention/control methods are also summarized.

1. MANAGEMENT OF
MALARIA
Magdalene Okon Ephraim
17051146046

2. OUTLINE
■ Introduction
■ Epidemiology
■ Etiology
■ Pathophysiology
■ Classification
■ Clinical features
■ Investigation
■ Differential diagnostic
■ Recurrent Malaria
■ Treatment
■ Complications
■ Prognosis
■ Prevention and
Control
■ References

3. INTRODUCTION
Malaria is an infection that is caused by a few
plasmodium species that is spread by the vector
mosquito in the favorable temperature (20-30oC).
Once they enter the bloodstream, they start to
infect and destroy the liver and red blood cells
which will lead to a myriad of symptoms and when
severe could result in death eventually.

4. EPIDEMIOLOGY
 Malaria affects millions of people especially
• Young children under 5 years
• Pregnant women
• Patients with HIV/AIDS
• Travelers with no prior exposure
 Malaria is presently endemic in a broad band around the
equator, in areas of the north America, many parts of Asia, and
much of Africa; in Sub-Saharan Africa, 85–90% of malaria
fatalities occur.
 Malaria is endemic in 109 countries and is found throughout in
the tropics.

5. EPIDEMIOLOGY
• P. Falciparum predominates Africa, Papau New Guinea and Haiti
• P. Vivax in South America, North Africa, the Middle East and Indian
subcontinent
• P. Ovale is common mostly in west Africa
• P.malaria is found in most areas but uncommon outside Africa
 95% of malaria infections in Nigeria are caused by plasmodium
falciparum which also accounts for the majority of deaths.
 There are an estimated 100 million malaria cases with over
300,000 deaths per year in Nigeria. 30% childhood death,25% of
death in children below 1 year and 11% maternal death in Nigeria
 It’s accounts for 60% of out patients consultations in Nigeria

6. ETIOLOGY
Malaria is caused by infection with parasites in the genus
plasmodium
There are 5 species of plasmodium are known to infect humans and
they include;
■ Plasmodium malariae
■ Plasmodium vivax
■ Plasmodium ovale
■ Plasmodium falciparum
■ Plasmodium Knowlesi
The vector implicated is the female anopheles mosquito

7. PATHOPHYSIOLOGY

8. PATHOPHYSIOLOGY
■ Genetic resistance
Several genetic factors provide some resistance to it including sickle
cell trait, glucose-6-phosphate dehydrogenase deficiency and the
absence of Duffy antigens on red blood cells.
Sickle cell trait causes a change in the haemoglobin molecule in the
blood. Normally, red blood cells have a very flexible, biconcave shape
that allows them to move through narrow capillaries ; however, when
the modified hemoglobin S molecules are exposed to low amounts of
oxygen, or crowd together due to dehydration, they can stick together
forming strands that cause the cell to distort into a curved sickle shape.
In these strands, the molecule is not as effective in taking or releasing
oxygen, and the cell is not flexible enough to circulate freely.

9. CLASSIFICATION
Malaria is classified based on :
Epidemiology and Severity
1. There are 2 main
epidemiological types of
malaria:
■ Stable malaria
■ Unstable malaria
2. Based on severity malaria is
divided into:
■ Uncomplicated malaria
■ Complicated malaria
■ It is deemed complicated when any of the following
criteria are present, otherwise it is considered
uncomplicated.
1. Decreased consciousness
2. Significant weakness such that the person is unable to
walk
3. Inability to feed
4. Two or more convulsions
5. Low blood pressure (less than 70 mmHg in adults and
50 mmHg in children)
6. Respiratory distress
7. Circulatory shock
8. Kidney failure or hemoglobin in the urine
9. Bleeding problems, or haemoglobin less than 50 g/L
(5 g/dL)
10. Pulmonary edema
11. Blood glucose less than 2.2 mmol/L (40 mg/dL)
12. Acidosis or lactate levels of greater than 5 mmol/L

10. CLINICAL FEATURES
The clinical features seen are as
a result of the destruction of the
RBCs which causes anaemia and
production of cytokines
In uncomplicated malaria we see
■ fever
The fever occurs in
waves/paroxysms
 P. Malaria occurs every 72
hrs= quartan fever
 P. Ovale and vivax occurs
every 48 hrs= tertian fever
 P. Knowlesi occurs every 24 hrs
 P. Falciparum fever varies
between 24-48 hrs hence the
pattern is called malignant tertian
fever
■ Headaches
■ Malaise
■ Jaundice
■ Chills
■ Extreme Fatigue
■ Lack of appetite
■ Generalized body pains
■ Metallic / bitter taste in the mouth

11. CLINICAL FEATURES
■ In complicated malaria we see:
 Cerebral malaria:altered mental status, seizures, Coma
 Bilious malaria: diarrhea, vomiting, jaundice ,liver failure
 Spleen, lungs, kidney: presents with features of sepsis
which includes- flushing, shivering, hyperpyrexia
(temp>41•c), convulsions, bleeding from orifices,
respiratory distress, hypoglycemia, renal failure,
pulmonary edema

12. INVESTIGATIONS
The methods for laboratory
diagnosis of malaria can be
broadly classified into:
■ Microscopic tests
■ Non-microscopic tests
Microscopic tests
1. Thick film- for parasite
detection
2. Thin film- for particular
species of parasite
Stains used are giemsa, field’s,
or leishman stains
https://www.cdc.gov/dpdx/index.
html
Non-microscopic tests
These tests detect plasmodial antigens,
anti plasmodial antibodies and plasmodial
nucleic acids
■ Plasmodial antigen detection: antigen
based rapid diagnostic test , gel
diffusion , counter
immunoelectrophoresis,
radioimmunoassay, enzyme
immunoassay.
■ Anti plasmodial antibodies detection:
haemaglutination, enzyme
immunoassay,
immunochromatography, western blot.
■ Plasmodial nucleic acid detection:
polymerase chain reaction.

13. INVESTIGATIONS

14. DIFFERENTIAL DIAGNOSIS
Malaria infection has to be
differentiated from other
diseases that would cause
fever, chills, generalized body
pains, etc. Some of these
disease includes
■ Ebola virus
■ Salmonelliosis
■ Lassa fever
■ Dengue virus
■ Influenza
■ Tuberculosis
■ Amoebic liver disease
■ Acute schistosomiasis
■ Hepatitis
■ Acute HIV

15. TREATMENT
Malaria is treated with anti malaria medications; the ones used
depends on the phases in the life cycle, severity of the disease and for
chemoprophylaxis.
Based on the severity;
1. Uncomplicated Malaria:Artemisinin in combination with other
antimalarials (known as artemisinin combination therapy or ACT) is
about 90% effective when used to treat uncomplicated
malaria.some combinations include:
■ Artemether + lumefantrine(six dose regimen)
■ Dihydroartemisinin+ piperaquine
■ Artemisinin+naphthoquine
■ Artesunte+mefloquine

16. TREATMENT
2. Complicated malaria
Recommended treatment for severe malaria is
the intravenous use of antimalarial drugs. For severe
malaria, parenteral artesunate was superior to quinine in both
children and adults.
Treatment of severe malaria involves supportive measures that
are best done in a critical care unit. This includes the
management of high fevers and the seizures that may result
from it. It also includes monitoring for respiratory distress,
hypoglycemia, and hypokalemia

17. TREATMENT
■ Based on stage of cycle
1. Exoerythrocytic and Gametocytic stages(Eliminating tissue
schizonts)
 Proguanil + Atovaquone
 Primaquine
2. Erythrocytic stage (Eliminating blood schizonts)
 ACTs mainly
 Chloroquine
 Quinine
 Mefloquine
 Doxycycline

18. TREATMENT
■ To treat malaria during pregnancy, the WHO recommends the
use of quinine plus clindamycin early in the pregnancy (1st
trimester), and ACT in later stages (2nd and 3rd
trimesters).There is limited safety data on the antimalarial
drugs in pregnancy.
■ Chemoprophylaxis therapy for travelers from non-malarious to
malarious regions include
pyrimethamine,proguanil,chlorproguanil,
atovaquone,chloroquine ,mefloquine, atovaquone-proguanil,
doxycycline and primaquine
Recommendations of this therapy vary considerably depending
on the risk, prevalence, and drug resistance

19. RECURRENT MALARIA
Symptoms of malaria can recur after varying symptom-free periods.
Depending upon the cause, recurrence can be classified as
either recrudescence , relapse, or reinfection.
 Recrudescence is when symptoms return after a symptom-free
period due to failure to remove blood-stage parasites by adequate
treatment.
 Relapse is when symptoms reappear after the parasites have been
eliminated from the blood but have persisted as
dormant hypnozoites in the hepatocytes. Relapse commonly occurs
between 8 and 24 weeks after the initial symptoms and is often
seen in P. vivax and P. ovale infections.
 Reinfection means that parasites were eliminated from the entire
body but new parasites were then introduced.

20. COMPLICATIONS
■ Acute complications include: Shock, heart failure and convulsions.
■ Chronic complications of malaria is associated with the following specific
syndromes:
Nephrotic syndrome of quartan malaria , chronic hepatosplenomegaly,
Burkitt's lymphoma, chronic anaemia, chronic ill -health, failure to thrive,
vulnerability to other infections and retardation of educational development.
■ In pregnancy it can lead to still births, infant mortality, miscarriages or low
birth weight

21. PROGNOSIS
■ Most patients with uncomplicated malaria exhibit marked
improvement within 48 hours after the initiation of treatment
and are fever free after 96 hours. P falciparum infection carries
a poor prognosis with a high mortality rate if untreated.
However, if the infection is diagnosed early and treated
appropriately, the prognosis is excellent.
■ When properly treated, people with malaria can usually expect
a complete recovery. However, severe malaria can progress
extremely rapidly and cause death within hours or days.In the
most severe cases of the disease, fatality rate can reach 20%,
even with intensive care and treatment.

22. PROGNOSIS
■ During childhood, malaria causes anaemia during a
period of rapid brain development, and also direct brain
damage resulting from cerebral malaria. Some survivors
of cerebral malaria have an increased risk of
neurological and cognitive deficits, behavioral disorders
and epilepsy. Malaria prophylaxis was shown to improve
cognitive function and school performance in clinical
trials when compared to placebo groups.

23. PREVENTION AND CONTROL
METHODS PURPOSE
Source reduction • Discouraging egg laying
Larvicides • To prevent development of
eggs into larvae and adults
Adult insecticides • To kill adult mosquitoes
Personal protection : use of
• insecticide treated nets and
indoor residual spraying
• Wearing full clothing in swampy
area
• Emptying and clearing stagnant
water in surrounding
• To prevent mosquitoes from
biting human beings and deny
any blood meal
• Prevention of invasion of
mosquitoes into places of
human dwelling

24. REFERENCES
■ Kumar and Clarke 9th Edition
■ Medscape
■ Osmosis.org

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