malaria presentation and management who

1. A case of
Tropical fever
Dr. Aiswarya Bharathi ​

2. Case History
• 26 y.o. male with h/o giddiness followed by brief episode of
unresponsiveness, asso. with sweating;
• h/o bifrontal headache and fever x 3 days
• h/o travel from Africa 1 week back;
• No h/o seizures/ rashes/ constitutional/urinary symptoms/ bowel/
bladder dysfunction
• O/E – BP 100/50 mmHg; T 98.7 F; RR 22; HR 82 bpm; spo2 98%
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3. • S/E
• CVS – S1S2 no murmurs;
• RS – B/L AE+ No crepts;
• PA – soft, no G/R, No organomegaly; non tender;
• CNS – GCS 15/15; PEARL; NFND; No nuchal rigidity;
Motor/sensation intact; Cerebellar signs –ve
• No pallor/LN/Icterus/Clubbing/PE
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4. • Provisional diagnosis?
• Differentials?
• Investigations to order?
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5. • ECG – NSR
• CBC – Hgb 10.1 PCV 41 TC 2180 Plt 1,29000 DC N76L22M2E0
• SERUM ELECTROLYTES Na 138 K 3.27 Cl 108 HC03 23
• LFT – T. Bil 1.35; D.Bil – 0.88; AST/ALT – 68/73; GGT 79
• RFT – Urea/ Creat – 30/1.73
• mpQBC positive
• PS – Pancytopenia
5

6. Malaria

7. • Malaria is transmitted by the female anopheline mosquito and
leads to a protozoan infection of red blood cells.
• The most severe form of malaria is caused by plasmodium
falciparum, and this can lead to cerebral malaria.
• The definition of cerebral malaria is coma in a patient infected with
plasmodium falciparum, with no other cause for the coma.
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8. Etiology
Four species of Plasmodium (P. falciparum, P. vivax, P. malariae and P.
ovale) most commonly infect humans. P. falciparum and P. vivax are the
most prevalent species and P. falciparum is the most dangerous.
A fifth species, P. knowlesi (a species of Plasmodium that primarily infects non-human primates)
is increasingly being reported in humans inhabiting forested regions of some countries of South-
East Asia and the Western
Pacific regions, and in particular on the island of Borneo.
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9. Transmission
• The survival and longevity of female mosquitoes is of critical
importance in malaria transmission, as the malaria parasite
generally requires a period of 7–10 days to develop inside the
mosquito into a form that is infective to humans.
• Anopheles mosquitoes lay their eggs in water. The eggs hatch to
produce larvae, which undergo several moults before emerging
from the pupal stage as adult mosquitoes.
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10. 10

11. CEREBRAL MALARIA
• In cerebral malaria, plasmodium falciparum-infected red blood cells
bind to the blood-brain barrier endothelium, and in so doing,
significantly decrease blood-brain barrier resistance to invasion by
the parasite.
• Altered consciousness may occur as a direct result of cerebral
infection, or as a consequence of convulsions, hypoglycaemia or
acidosis.
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12. CEREBRAL MALARIA
SIGNS
Patients may present with
either of the following:
Cortical signs:
Drowsiness or confusion
Seizures
Decorticate rigidity
Brainstem signs:
Decerebrate rigidity
Opisthotonos
Pupillary changes
Absent corneal reflexes
Abnormal respiratory
patterns
Gaze abnormalities
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13.  Impaired consciousness/coma
 Repeated generalized convulsions
 Renal failure (Serum Creatinine >3 mg/dl)
 Jaundice (Serum Bilirubin >3 mg/dl)
 Severe anaemia (Hb 106°F or >42°C)
 Hyperparasitaemia (>5% parasitized RBCs
 Microscopic evidence may be negative for asexual in
patients with severe infections due to sequestration and
partial treatment. Efforts should be made to confirm these
cases by RDT or repeat microscopy.

14. STANDARD TREATMENT
GUIDELINES MALARIA,
NVBDCP, INDIA
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15. Diagnosis
• Microscopy of stained thick and thin films is the gold standard for
confirmation of diagnosis of malaria
• Sensitivity is high; distinguish different species of malaria
• RDTs – based on detection of circulating parasite antigens
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16. Treating Uncomplicated Malaria
• Confirmed P. vivax cases should be treated with chloroquine in full
therapeutic dose of 25 mg/kg as per the age-wise dosage schedule.
• Primaquine is contraindicated in pregnant women, infants and known
G6PD deficient patients – can lead to hemolysis.
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17. 17

18. Treating P.Falciparum Malaria
• Artemisinin Combination Therapy (ACT) should be given to all the
confirmed P. falciparum cases found positive by microscopy or
RDT. This is to be accompanied by single dose of primaquine (0.75
mg/kg body weight) on Day 2.
• ACT consists of an artemisinin derivative combined with a long-
acting antimalarial (amodiaquine, lumefantrine, mefloquine,
piperaquine or sulfadoxine-pyrimethamine).
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19. 19

20. 20

21. Northeastern states
• The ACT recommended except northeastern states is artesunate
(4 mg/kg body weight) daily for 3 days and sulfadoxine (25 mg/kg
body weight) –pyrimethamine (1.25 mg/kg body weight) [AS+SP]
on Day 0.
• In the northeastern states (Arunachal Pradesh, Assam, Manipur,
Meghalaya, Mizoram, Nagaland, and Tripura), recommended ACT
in national drug policy is fixed dose combination (FDC) of
Artemether-lumefantrine (AL).
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22. In pregnancy & mixed infections
The ACT should be given for treatment of P. falciparum malaria in
second and third trimesters of pregnancy, while quinine is
recommended in the first trimester. Plasmodium vivax malaria can
be treated with chloroquine.
Treatment of mixed infections
Mixed infections with P. falciparum should be treated as falciparum
malaria. Since AS+SP is not effective in vivax malaria, other ACT
should be used.
However, anti-relapse treatment with primaquine can be given for 14
days, if indicated.
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23. Severe malaria
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• Artesunate: 2.4 mg/kg body weight i.v. or i.m. given on
admission (time=0), then at 12 and 24 hours, then once a day
(Care should be taken to dilute artesunate powder in 5% Sodium
bi-carbonate provided in the pack)
• Quinine: 20 mg quinine salt/kg body weight on admission (i.v.
infusion in 5% dextrose/dextrose saline over a period of 4 hours)
followed by maintenance dose of 10 mg/kg body weight 8 hourly;
infusion rate should not exceed 5 mg/kg body weight per hour.
Loading dose of 20 mg/kg body weight should not be given, if the
patient has already received quinine.
• NEVER GIVE BOLUS INJECTION OF QUININE.

24. • Artemether: 3.2 mg/kg body weight i.m. given on admission
then 1.6 mg/kg body weight per day.
• Arteether: 150 mg daily i.m. for 3 days in adults only (not
recommended for children).
• Intravenous preparations should be preferred over intramuscular
preparations. Parenteral treatment should be given for minimum of
24 hours once started.
• In first trimester of pregnancy, parenteral quinine is the drug of
choice. However, if quinine is not available, artemisinin
derivatives may be given to save the life of mother.
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25. 25

26. Chemoprophylaxis
Short-term chemoprophylaxis (less than 6 weeks)
• Doxycycline: 100 mg daily in adults and 1.5 mg/kg body weight for
children more than 8 years old. The drug should be started 2 days
before travel and continued for 4 weeks after leaving the malarious
area.
• Note: Doxycycline is contraindicated in pregnant and lactating
women and children less than 8 years.
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27. Long-term chemoprophylaxis (more than 6 weeks)
• Mefloquine: 5 mg/kg body weight (up to 250 mg) weekly and
should be administered two weeks before, during and four weeks
after leaving the area.
• Note: Mefloquine is contraindicated in cases with history of
convulsions, neuropsychiatric problems and cardiac conditions
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28. WHO GUIDELINES 2023
MALARIA
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29. Diagnosing Malaria
• All cases of suspected malaria should have a parasitological test
(microscopy or RDT) to confirm the diagnosis.
• Both microscopy and RDTs should be supported by a quality
assurance programme.
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30. Treating Uncomplicated Malaria
• Artemisinin-based combination therapy
• Artemisinin-based combination therapy (2015)
• Children and adults with uncomplicated P. falciparum malaria should be
treated with one of the following
• ACTs*:
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• artemether-lumefantrine (AL)
• artesunate-amodiaquine (AS+AQ)
• artesunate-mefloquine (ASMQ)
• dihydroartemisinin-piperaquine (DHAP)
• artesunate + sulfadoxine-pyrimethamine
(AS+SP)
• artesunate-pyronaridine (ASPY) (2022)

31. Treatment/Dosing
• ACT regimens should provide 3 days’ treatment with an artemisinin
derivative.
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32. Children
Revised dose recommendation for dihydroartemisinin +
piperaquine in young children (2015)
• Children weighing <25kg treated with dihydroartemisinin +
piperaquine should receive a minimum of 2.5 mg/kg bw per day of
dihydroartemisinin and 20 mg/ kg bw per day of piperaquine daily
for 3 days.
• Infants weighing < 5 kg with uncomplicated P. falciparum malaria
should be treated with an ACT at the same mg/kg bw target dose
as for children weighing 5 kg.
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33. Pregnant & lactating mothers
Treatment in the first trimester of pregnancy (2022)
• Pregnant women with uncomplicated P. falciparum malaria should
be treated with artemether-lumefantrine during the first trimester.
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34. Uncomp. Malaria caused by
ovale/vivax/knowlesia/malariae
Blood stage infection (2015)
• If the malaria species is not known with certainty, adults and
children should be treated as for uncomplicated P. falciparum
malaria.
• In areas with chloroquine-susceptible infections, adults and
children with uncomplicated P. vivax, P. ovale, P. malariae or P.
knowlesi malaria should be treated with either an ACT or
chloroquine.
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35. Preventing relapse
Preventing relapse in P. vivax or P. ovale malaria (2015)
• To prevent relapse, children and adults (except pregnant women,
infants aged < 6 months, women
• breastfeeding older infants unless they are known not to be G6PD
deficient, and people with G6PD deficiency)
• should be treated with a 14-day course of primaquine in all
transmission settings.
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36. Short-course standard dose primaquine treatment (2022)
• To prevent relapse, an additional treatment option of using
primaquine 0.5 mg/kg/day for seven days is recommended to treat
P. vivax or P. ovale malaria in children and adults (except pregnant
women, infants aged < 6 months, women breastfeeding infants
aged < 6 months, women breastfeeding older infants unless they
are known not to be G6PD deficient, and people with G6PD
deficiency).
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37. Treating severe malaria
• Adults and children with severe malaria should be treated with
intravenous or intramuscular artesunate for at least 24 h and until
they can tolerate oral medication.
• Once a patient has received at least 24 h of parenteral therapy and
can tolerate oral therapy, treatment should be completed with 3
days of an ACT.
• Children weighing < 20 kg should receive a higher dose of
artesunate (3 mg/kg bw per dose) than larger children and
adults (2.4 mg/kg bw per dose) to ensure equivalent exposure
to the drug
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38. Travellers chemoprophylaxis
In summary, travellers should start chemoprophylaxis before
entering an endemic area.
Malaria may be prevented by taking drugs that inhibit liver-stage
(pre-erythrocytic) development (causal prophylaxis) or drugs that kill
asexual blood stages (suppressive prophylaxis).
Causal prophylactics (atovaquone + proguanil) can be stopped
soon after leaving an endemic area, whereas suppressive
prophylactics must be taken for at least 4 weeks after leaving the
area in order to eliminate asexual parasites emerging from the liver
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39. IRS
• Indoor residual spraying (2019)
• IRS should be deployed for the prevention and control of malaria in
children and adults living in areas with ongoing malaria
transmission.
• WHO recommends that WHO-prequalified insecticidal products be
selected for IRS use and that these be selected based on the
insecticide susceptibility of the local malaria vectors
Pyrethroids; Organochlorines (e.g. DDT)
Acetylcholinesterase inhibitors
Organophosphates: malathion, fenitrothion, pirimiphos-methyl
Carbamates: bendiocarb, propoxur
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40. Global technical strategy for
malaria 2016-2030
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41. Intermittent preventive treatment of malaria in pregnancy (2022)
• In malaria-endemic areas, pregnant women of all gravidities should
be given antimalarial medicine at predetermined intervals to
reduce disease burden in pregnancy and adverse pregnancy and
birth outcomes.
• Sulfadoxine-pyrimethamine (SP) has been widely used for
malaria chemoprevention during pregnancy and remains effective
in improving key pregnancy outcomes.
• IPTp-SP should ideally be administered as directly observed
therapy (DOT) with three tablets of SP (each tablet containing 500
mg/25 mg SP), for the total required dosage of 1500 mg/75 mg SP.
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42. IS there a vaccine against
malaria? ​
RTS,S/AS01 (RTS,S) is
the first and, to date,
only vaccine that has
demonstrated it can
significantly reduce
malaria in young children
living in moderate-to-
high malaria
transmission areas.
It acts against the
Plasmodium falciparum.
In 2019, Ghana, Kenya
and Malawi began
leading the introduction
of the vaccine in
selected areas as part of
a large-scale pilot
programme coordinated
by WHO.
As of March 2023, more
than 1.3 million children
had received at least 1
dose of the vaccine
through this programme.
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43. Back to our patient..
43

44. • Our patient had a smear proven P.falciparum malaria. He’d
received Inj Falcigo 120 mg IV OD; Tab. Lumerax 80 mg BD and
Inj Clindamycin 600 mg IV TDS in outside hospital.
• Initial deranged LFTs and RFTs. CT Brain Normal.
• In hospital - continued with Inj Artesunate and Lumerax. Liver
parameters improved;
• Discharged after __ days.
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45. Thank you