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MALARIA
Malaria : Historical perspective
In 1880, Laveran, a French physician in Algeriaidentified causative organism of Malaria. Recd Nobel
Prize in 1907
August 20th 1897 Sir Ronald Ross, while workingin India demonstrated oocyst in gut of Anophelene
mosquito.This day is celebrated as Mosquito
Day
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Malaria - Facts sheet : 40% of world population ( > 240 Cr. people )
areexposed to malaria in 100 countries. WHO 1995
50 Cr. get it every year
10 L people die of malaria every year India contributes 80% of total cases
Orissa with only 3% of Indias population
contributes 25% of total reported cases ofmalaria in India
NMEP ( 1997 ) reported P Falcip 40% &
P Vivax 60%.
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Plasmodium species which
infect humans
Plasmodium vivax( B. tertian)
Plasmodium ovale ( B. tertian)
Plasmodium falciparum ( M.tertian)
Plasmodium malariae (quartian)
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Anopheles mosquito : Facts
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Exo-erythrocytic(hepatic) cycle
Sporozoites
Mosquito SalivaryGland
Malaria LifeCycleLife Cycle
Gametocytes
Oocyst
ErythrocyticCycle
Zygote
Schizogony
Sporogony
Hypnozoites
(for P. vivaxand P. ovale)
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Malaria Transmission Cycle
Parasite undergoes
sexual reproduction inthe mosquito
Some merozoites
differentiate into male orfemale gametocyctes
Erythrocytic Cycle:Merozoites infect red
blood cells to formschizonts
Dormant liver stages
(hypnozoites) ofP.vivax and P. ovale
Exo-erythrocytic (hepatic) Cycle:
Sporozoites infect liver cells and
develop into schizonts, which releasemerozoites into the blood
MOSQUITO HUMAN
Sporozoires injected
into human host duringblood meal
Parasites
mature in
mosquito
midgut and
migrate to
salivaryglands
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Components of the Malaria Life Cycle
Mosquito Vector
Human Host
Sporogonic cycle
Infective Period
Mosquito bites
gametocytemic
person
Mosquito bites
uninfected
person
Prepatent Period
Incubation Period
Clinical Illness
Parasites visible
Recovery
Symptom onset
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Fever 1 month
Nausea 15 days
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Past H/O:Nothing contributory
Drug H/O:Tab. Ciprofloxacin
Travel H/O:He went to his village
(Kurigram) 7 days priorto fever
On Ex.:Temp. 102F
(chill and rigor)Pulse 120 /min.
BP 110 / 80 mmHg
RR 24 / min.JVP not raised
Pallor present
Jaundice mild (+)
Clubbing absent
Lymph node not palpable
Thyroid gland not palpable
Systemic Ex.:CVS - Normal
RS - Normal
GIT - Hepato splenomegaly
Other system revealed no abnormality
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Fever
Nausea
Malaria, Kalazar, Enteric
Hepatitis
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CBC:
ESR - 56 mm 1st hour
Hb% - 11.5 mg /dl
TLC - 3,480 /cumm[ (N) - 58%, (L) - 36%, No band ]
Widal:not significant
LFT:
T. Bilirubin - 37 umol/L ( )
Alka. Phos. - 94 u/L (~)
ALT - 68 u/L ( ) AST - 61 u/L ( )
Urine R/M/E:normal
X-ray Chest:
Normal
USG ofWhole Abdomen:
Hepato splenomegaly
Blood C/S:
No organism
ICT for Malaria: Positive
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Rapid Diagnostic Tests :Rapid Diagnostic Tests :
Assays for detection of pLDH : It is a soluble enzymeexpressed at high levels in asexual stages of malarialparasite. It is present in all four species of Plasmodium. 3antibodies are used to detect it. Two are for all 4 species ;
3rd is specific for P Falciparum. Sensitivity is similar to or less
than microscopy sp at
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WHO recommendations on
Rapid Diagnostic Tests :
These tests are recommended when microscopy not
available or inconclusive. These tests are fast & simple
They are fairly sensitive and specific
These tests are particularly helpful in partially treated cases
or when microscopy is negative The tests can be very useful when the patient reports after
the working hours
Monitoring parasite clearance, quantification of parasite
load, and stage identification is not possible with thesetests
THICK FILM SHOULD BE EXAMINED IN ALLSUSPECTED CASES OF MALARIA
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Clinical presentation : childrenClinical presentation : children
Anemia + + +
Convulsions + + +
Hypoglycemia + + +
Jaundice + Renal failure
Pulmonary edema +
Neurological sequelae aremore common (15%)
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P. falciparum
P. malariae
P. vivax
P. ovale
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Complications
Cerebral malaria
Hypoglycaemia
Hyperpyrexia
ConvulsionShock
Hemoglobinuria
Severe anaemia
Acute renal failure
Coagulopathy
Spontaneous bleeding
Acute pulmonary oedemaAspiration pneumonia
Hyperparasitaemia
Metabolic acidosis
Glomerulonephritis
Nephrotic syndrome
Herpes simplex
Relapses
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Malarial Paroxysm
Can get prodrome 2-3 days before Malaise, fever,fatigue, muscle pains, nausea, anorexia
Can mistake for influenza or gastrointestinal infection
Slight fever may worsen just prior to paroxysm
Paroxysm
Cold stage - rigors
Hot stage Max temp can reach 40-41o C,splenomegaly easily palpable
Sweating stage Lasts 8-12 hours, start between midnight and midday
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Malarial Paroxysm
Periodicity
Days 1 and 3 for P.v., P.o., (and P.f.) - tertian
Usually persistent fever or daily paroxyms for
P.f.
Days 1 and 4 for P.m. - quartian
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Aims of treatment :Aims of treatment : To kill allTo kill all schizontsschizonts as fast and as completely asas fast and as completely as
possible (we are not concerned much about gametespossible (we are not concerned much about gametesas they do not cause disease in the patient concerned,as they do not cause disease in the patient concerned,but cause transmission to others)but cause transmission to others)
To kill hepatic parasites (To kill hepatic parasites ( hypnozoiteshypnozoites in Pin P VivaxVivax ))which causes recrudescence or relapsewhich causes recrudescence or relapse
To treat other associated abnormalitiesTo treat other associated abnormalities
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Treatment
Plasmodium vivax:
Tab. Chloroquine (CQ) + Tab. Primaquine (PQ) CQ3 + PQ14
Uncomplicated Malaria
Presumptive
:
Tab. Chloroquine (CQ) CQ3
Severe Malaria :
IV Quinine drip / IM Quinine followed by
Oral Quinine for a total of 7 days
Or, IM Artemether / IV Artesunate followed by
Oral Artesunate tablet
Uncomplicated Malaria Confirmed
:
Tab. Co-artem (Artemether + Lumefantrine) 4 tab. 12H, 3 days
Or, Tab. Quinine 2 tab. 8H, 7 days
Alternative,
Tab. Quinine (Q) + Tab. Tetracycline (T) Q7 + T7
Or, Tab. Quinine (Q) + Tab. Doxycycline (D) Q7 + D7
Or, Tab. Artisunate (A) + Tab. Mefloquine (M) A3 + M2
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Plasmodium vivax:
Tab. Chloroquine (CQ) + Tab. Primaquine (PQ) CQ3 + PQ14
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More choices means moreMore choices means moreconfusion !!!confusion !!!
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QUININE :QUININE : INJ 300 mg / ml :INJ 300 mg / ml :
11STST DOSE 20 mg / kgDOSE 20 mg / kgThen 10 mg / kg B DThen 10 mg / kg B D
TAB 300mg / 600 mg ; 600 mg 8TAB 300mg / 600 mg ; 600 mg 8 hrlyhrly
CHILDREN 10 mg 8CHILDREN 10 mg 8 hrlyhrly FOR 7 DAYSFOR 7 DAYS
Side effects : hypotension, hypoglycemia,Side effects : hypotension, hypoglycemia,arryhthmiaarryhthmia
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CHLOROQUINE :CHLOROQUINE : TAB 250 mg / 500mgTAB 250 mg / 500mg
2 TAB ( 600 mg BASE ) STAT2 TAB ( 600 mg BASE ) STAT1 TAB AFTER 6 HOURS1 TAB AFTER 6 HOURS
1 TAB OD FOR 2 DAYS.1 TAB OD FOR 2 DAYS.
Prophylactic : 300 mg ( base ) / weekProphylactic : 300 mg ( base ) / week
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Mefloquine :Mefloquine :
250 mg Tab
Dose: 20 mg / kg in 1 or 2 doses
Good for combination therapy and
prophylactic therapy ( once a week )
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Primaquine :Primaquine :
Only effective drug against hypnozoites.
Thus to be used for radical cure of vivaxmalaria
Dose 15 mg / day for 15 days
Check for G 6 P D deficiency as it may
cause hemolysis in deficient people.
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Rapidly acting blood schizontocidal antimalarials
against chloroquine sensitive and chloroquine resistantfalciparum as well as vivax malaria
They quickly arrest the ring or the trophozoite
development and also prevent pathological sequelae
Fever subsides and parasites are cleared rapidly Defervescence occurs within 2-3 days after drug
administration
90% clearance of asexual erythrocytic
parasitaemia is usually observed within 4 hours
(Valecha N. et al., Indian Journal of Pharmacology, 1997)
Artemesinin:Artemesinin:
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Malaria and pregnancy :Malaria and pregnancy : Quinine, chloroquine, S P can be used safely in any
trimester.
Artesunate, artemether and mefloquine can be use in
IInd and IIIrd trimesters.
Clindamycin can be used in pregnancy.
Doxycycline and primaquine are contraindicated.
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Treatment of malaria in infants :Treatment of malaria in infants : Malaria is common in infants in endemic countries as
immunity from mother wanes after 46 months.
Case fatality rate is higher in infants than in older
children.
Dosing should be proper.
With increasing failure of chloroquine and SP challenge
is to find good drugs.
Luckily artemesinins are safe and well tolerated.
Even rectal administration could be done.
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Special consideration in childreSpecial consideration in childre
Fluid < 5 kgFluid < 5 kg ------ 150ml / kg / day150ml / kg / day
55 10 kg10 kg 120ml/kg/day120ml/kg/day
1111--19 kg19 kg 80 ml/kg/ day80 ml/kg/ day
Packed CellsPacked Cells ------ 20ml / kg over 320ml / kg over 3--4 hrs4 hrs
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WHO-Current and Future directionsDrug management of malaria
Malaria endemic countries which are experiencinghigh levels of resistance to currently used anti-malarial
drugs as monotherapy are advised to switch over to
combination therapy
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OTHER MEASURESOTHER MEASURES
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THANK YOU
SHRIDEEP PARAB
GROUP NO 33
6TH COURSE
ENGLISH MEDIUM
SARATOV-2010