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8/10/2019 Malaria Clin&Manag S1
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Malaria
Malaria is a protozoan disease transmitted by the bite ofinfectedAnophelesmosquitoes.
Most important of the parasitic diseases of humans, withtransmission in 103 countries affecting more than 1 billionpeople and causing between 1 and 3 million deaths each year
Four (or 5 ?) species of the genus Plasmodiumcause nearlyall malarial infections in humans : P. falciparum, P. vivax, P.ovale, and P. malariae(the 5th is P. knowlesi)
Almost all deaths are caused by falciparum malaria.
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CLINICAL FEATURES Clinical symptoms include the following: Fatigue,
Malaise, Shaking chills, Arthralgia, Myalgia, Paroxysm offever, shaking chills, and sweats
The classic paroxysm begins with a period of shiveringand chills, which lasts for approximately 1-2 hours, andis followed by a high fever. Finally, the patientexperiences excessive diaphoresis, and the bodytemperature of the patient drops to normal or belownormal
Less common symptoms include the following:
Anorexia and lethargy Nausea and vomiting
Diarrhea
Headache
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Laboratory examination Giemsa-stained thick and thin peripheral blood smears
These smears are the criterion standard for malaria
detection and should be sent to the laboratory
immediately, since malaria is a potentially life-
threatening infection.
When reading the smear, 200-300 oil-immersion
fields should be examined (more if the patient
recently has taken prophylactic medication, because
this temporarily may decrease parasitemia). Rapid diagnosis test
PF test, ICT test, paracheck, OptiMAL
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Manifestations of Severe Falciparum MalariaSigns Manifestations
Unarousable coma/cerebral malaria Failure to localize or respond appropriately to noxious stimuli; coma persisting for >30 min after
generalized convulsion
Acidemia/acidosis Arterial pH
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Differential Diagnosis
Typhoid fever
Dengue Fever URTI
Leptospirosis
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ALGORITME MALARIA CASE MANAGEMENT
No Rapid Test &
No Microsc
Microscopic Exam
No evidence:
URTITYPHOID
UTI
DENGUE
Leptospirosis
Other Infection
FalciparumMixed/F+VVivax
SEVEREMILD /
MODERATE Parasite ++++/>5% or
/+complications ;
Cerebral
Icteric, Bil > 3mg%
Systolic 35
Oliguria+Creat> 3 mg%
Rapid Test ( Yes) &
No Microscopic
Step. I: CQ3+PQ1SEVEREMalaria
Treatment
Rapid Test + Rapid Test -
Microscopic Confirmation
Step. I: CQ3+PQ1
Step. I: CQ3+PQ1
STEP. I: CQ3+PQ14
Step. II: QN7+PQ1
Step. II: SP1+PQ1
Step. III: QN7+PQ1
No evidence:
URTI
TYPHOID
UTI
DENGUE
Leptospirosis
Other Infection
Step. II: QN7+PQ14
Step. III: CQ1+PQ1/ week
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Management of Severe Malaria
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Initial management of Severe Malaria
Clear & maintain airway
Position semiprone or on side
Weight patient, calculate dosage
Start antimalarial chemotherapy
Make rapid clinical assesment Exclude or treat hypoglycaemia
Asses state of dehydration
Measure & monitor urine output, if nes. Catheter, S.G
Diagnostic smear, rapid test, other lab test
Plan first 8 hrs i.v. fluid, including anti malarial, glucose, bloodtrasfussion
Consider CVP line
If temp. rectal > 39 C, r. clothes, tepid sp., fan, cooling
Lumbal puncture, to exclude meningitis
Anti convulsant, anti-microbials, vit.K
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SPECIFIC TREATMENT SEVERE
MALARIA ( Anti Malaria)
PARENTERAL
START IMMEDIATELY
DOSAGE, WEIGHT THE PATIENT
MONITORING RESPONSE
SWITCHED TO ORAL WHEN POSSIBLE
MONITORING SIDE EFFECTS
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ANTI MALARIAL THERAPY FOR S.M
QUININE
QUINIDINE
CHLOROQUINEARTEMISININ :
ARTESUNATE : I.V/ I.M / SUPPOSITORIES
ARTEMETHER : I.M
ARTEMISININ SUPP
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RECOMMENDED DOSES OF ANTI MALARIAL
DRUGS FOR TREATMENT OF
SEVERE/CEREBRAL MALARIA
Hypoglycemia, chinchonism,
tinnitus, hearing
impairment, nausea,dysphoria, vomiting,
prolonged QT interval,
dysrhythmias,
hypotension
20 mg of dihydrochloride salt/kg by iv
infusion over 4 hr, then after
loading, followed by 10 mg/kg over4 hr every 8 hr. Patients should not
received quinine or mefloquine
within last 24 hr
Alternatively, 7 mg of salt/kg can be
infused over a period of 30 min,
followed by 10 mg salt/kg over a
period of 4 hr, or
10 mg of salt/kg (500 mg for adult) by
i.v infusion over 8 hr continously 3 x
a day
Quinine
DRUGS SIDE EFFECTS
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RECOMMENDED DOSES OF ANTI MALARIAL
DRUGS FOR TREATMENT OF
SEVERE/CEREBRAL MALARIA
Hypotension
3.2 mg/kg im initially, followed by1.6 mg/kg daily. Not to be
given iv (1 amp = 80 mg)Suppositories, 10 mg/kg at 0 & 4hr followed by 7 mg/kg at24,36,48 & 60 hrs.
10 mg base/kg infusion atconstant rate over 8 hrs
followed by 15 mg/kg over 24hrs, or
3.5 mg base/kg 6 hourly or 2.5 mgbase/kg 4 hourly by im or scinjection. Total dose 25 mgbase /kg
Artemeter
DRUGS SIDE EFFECTS
Artemisinin
Chloroquine
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Artesunate
2,4 mg/Kg/ with 3-5 ml 5% Dekstrose, IV in 2
minutes. Repeat in 12 hours. Then every 24 hours with same dose
Oral Preparations after the patient can eat
and drink well
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Convulsions
I.v. diazepam 10 mgadult or rectal 0.5-1.0
mg/kg i.m paraldehyde o.1 mg/kgadult
Repeated conv- chlormethiazol infussion 0.8 %,
Phenytoin 5 mg/kg i.v. 20 minutes
Fosphenytoin 7.5 mg/kg i.v 20 mnutes
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HYPOGLYCAEMIA ( Bl. Sugar < 40 mg% )
Coma, 20 -50 ml 50% dextrose i.v. 510 minutes (
routine is not recommended )
Infussion 10 % dextrose ( children5% dextrose)
beware hyponatremia
Hypoglycaemia may developed Day 1 --- 7
Pushed 50% dextrose if necessary
Via nasogastric , beware gastric distension In peritoneal dialysis, add glucose in dialysis fluid
Prophylaxis and Self Treatment for Malaria
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Prophylaxis and Self-Treatment for MalariaDrug Prophylaxis Usage Adult Dosage Child Dosage
Mefloquine Used in areas where chloroquine-resistant malaria has
been reported
228 mg of base (250 mg of salt) orally,
once/weeka
45 kg: 1 tablet/week
Doxycyclineb Used as alternative to mefloquine 100 mg orally, once/day >8 years of age: 2 mg/kg per day orally;
maximum dose, 100 mg/d
Chloroquine Used in areas where chloroquine-resistant malaria has
notbeen reported
300 mg of base (500 mg of salt) orally,
once/week
5 mg of base/kg (8.3 mg of salt/kg) orally,
once/week; maximum dose, 300
mg of base
Proguanil (not available
in U.S.)
Used simultaneouslywithchloroquine as alternative to
mefloquine or doxycycline
200 mg orally, once/day, in
combination with weekly
chloroquine
10 years: 200 mg/d
Primaquinec Used for travelers only after testing for G6PD
deficiency; postexposure prevention for
relapsing malaria or prophylaxis
Postexposure: 15 mg of base (26.3 mg
of salt) orally, once/day for 14
days
Prophylaxis: 30 mg of base daily
0.3 mg of base/kg (0.5 mg of salt/kg)
orally, once/day for 14 days
Atovaquone-proguanilc Used as alternative to mefloquine 250/100 mg orally once/day 11-20 kg 62.5 mg/100 mg
21-30 kg 125 mg/50 mg
31-40 kg 187.5 mg/75 mg
>40 kg 250 mg/100 mg
Self-treatment
Pyrimethamine-
sulfadoxined
In areas with chloroquine-resistant malaria, should be
carried during travel by persons taking
mefloquine or doxycycline
3 tablets (75 mg of pyrimethamine and
1500 mg of sulfadoxine) orally,
as a single dose
5-10 kg: 1/2tablet
11-20 kg: 1 tablet
21-30 kg: 1 1/2tablets
31-45 kg: 2 tablets
>45 kg: 3 tablets
aTablets manufactured outside the United States contain 250 mg of base.
bNot in pregnant women or children
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