MALARIA

ESSENTIALS OF DIAGNOSIS

SYMPTOMS

HISTORY OF EXPOSURE IN A MALARIA-ENDEMIC AREA PERIODIC ATTACTS OF SEQUENTIAL CHILLS, FEVER & SWEATING, APYREXIA DIDERITA

HEADACHE, MYALGIA,

SIGNS
- SPLENOMEGALI, ANEMIA

LABORATOTIES
-

LEUKOPENIA
PARASITES IN RBC IDENTIFIED IN THICK OR THIN BLOOD FILMS

ETIOLOGY : SPOROZOA GENUS PLASMODIUM Plasmodia malaria : Pl. vivax Mal. tertiana benigna Pl. ovale Mal. ovale / T. benigna Pl. falciparum Mal. tropika / T. maligna Pl. malariae Mal. kuartana

Erytrocytic & Exo-RBC phase

Pl. vivax
Pl. ovale Pl. falcifarum Pl. malariae

EE II (+)

EE I (+)

EE II (-)

PATHOGENESIS (1) Prof. Dr. Yohana Kandow

THE ASEXUAL ERYTHROCYTIC IS RESPONSIBLE FOR THE SYMPTOMS: - FEVER, HEADACHE, NAUSEA & MUSCULAR PAIN

AT THE TIME SCHIZONTINFECTED RBC RUPTURE

- ENDOGENEOUS PYROGEN (INTERLEUKIN-1) AND MEDIATORS (KININS & CATHECTIN (TNF) RELATED

TO PATHOGENESIS?

PATHOGENESIS (2) Prof. DR. Yohana

* ENCEPHALOPATHY: ~ RBC CONTAINING SCHIZONTS & MALARIAL PIGMENT OBSTRUCT CEREBRAL CAPILLARIES & VENULES ~ CEREBRAL EDEMA MAY DEVELOP AS A RESULT OF AGONAL HYPOXIA

~ SEQUESTRATION OF PARASITIZED RBC IN BRAIN

& OTHER TISSUE RESULT FROM CYTOADHERENCE OF KNOBLIKE PROTUBERANCE ON THE RBC TO

ENDOTHELIUM

PATHOGENESI (3) Prof. DR.

Johana
~ DECREASED DEFORMITY OF INFECTED RBC SLUGGISH MICROVASCULAR FLOW

~ CEREBRAL ANAEROBIC GLYCOLYSIS & REDUCED

CEREBRAL OXYGEN TRANSPORT CEREBRAL MALARIA

PATHOGENESIS (4) Prof DR Johana

- ANEMIA: ~ HEMOLYSIS OF INFECTED RBC ~ RAPID SPLENIC REMOVAL ON NONPARASITIZED ERYTHROCYTES ~ DYSERYTHROPOISIS - THROMBOCYTOPENIA SEQUESTRATION IN THE SPLEEN

PATHOGENESIS (5) Prof DR Johana

- ACUTE RENAL FAILURE

ACUTE TUBULAR NECROSIS

ISCHEMIA RESULTING FROM: ~ HYPOVOLEMIA ~ RENAL VASOCONTRICTION ~ MICROVASCULAR OBSTRUCTION: * PARASITIZED RBC * PIGMENT NEPHROPATHY SECONDARY TO HEMOLYSIS

ACUTE RENAL FAILURE

PATHOGENESIS (6) Prof DR Johana

- THE SPLEEN IS LARGE: ~ ENGORGE & HEAVILY PIGMENTED ~ CONTAINING MANY PHAGOCYTIC CELLS INGESTED RBC & MALARIAL PIGMENT - EDEMATOUS LUNGS: ~ PULMONARY CAPILLARIES & VENULE ARE PACKED WITH INFLAMMATORY CELLS

~ ENDOTHELIAL & INTESTINAL EDEMA

CLINICAL FINDINGS (1)

A. SYMPTOMS (1)
- SHAKING CHILLS (THE COLD STAGE) - FEVER (THE HOT STAGE) 41C - DIAPHORESIS (THE SWEATING STAGE) - FATIGUE - HEADACHE - DIZZINESS - MYALGIA - ARTHRALGIA - BACKACHE - DRY COUGH APIREKSI KERINGAT DINGIN DEMAM

DI-DE-RI-TA

CLINICAL FINDNGS (2)

SYMPTOMS (2)

- GASTROINTESTINAL SYMPTOMS:
~ ANOREXIA ~ NAUSEA

~ VOMITING
~ DIARRHEA ~ ABDOMINAL CRAMPS

CLINICAL FINDINGS (3)

SYMPTOMS (3)
-THE ATTACKS PERIODICITY: ~ EVERY-DAY FALCIPARUM

~ EVERY-OTHER-DAY TERTIAN PL. VIVAX & OVALE

~ EVERY-THIRD-DAY QUARTIAN PL. MALARIAE ~ TIRED BETWEEN ATTACKS, BUT FEELS WELL ~ AFTER THIS PRIMARY EPISODE, RECURRENCE ARE COMMON, EACH SEPERATED BY A LATENT PERIOD

CLINICAL FINDINGS (4) SIGNS

- SPLENOMEGALY: APPEAR ACUTE SYMPTOMS CONTINUED 4 DAYS - MILDY HEPATOMEGALY - ANEMIA

COMPLICATIONS (1):
1. CEREBRAL MALARIA: - HEADACHE - MENTAL DISTURBANCES - NEUROLOGIC SIGNS - RETINAL HEMORRHAGES - CONVULSIONS - DELIRIUM

- COMA

COMLICATIONS (2):
2. HYPERPYREXIA

3. HEMOLYTIC ANEMIA
4. NONCARDIOGENIC PULMONARY EDEMA 5. ACUTE TUBULAR NECROSIS & RENAL

FAILURE BLACKWATER FEVER DUE TO

>QUININE TREATMENT

COMPLICATIONS (3)
6. ACUTE HEPATOPATHY MARKED JAUNDICE, BUT NO LIVER FAILURE 7. HYPOGLYCEMIA 8. ADRENAL INSUFFICIENCY-LIKE SYNDROME 9. CARDIAC DYSRHYTHMIAS 10, GASTROINTESTINAL SYNDROMES 11. LACTIC ACIDOSIS & HYPOGLYCEMIA 12. PNEUMONIA 13. WATER & ELECTROLYTE IMBALANCE

MANAGEMENT:
A. TREATMENT OF ACUTE ATTACKS (1)
1. ELIMINATION OF ASEXUAL ERYTHROCYTIC PARASITES - CHLOROQUINE PHOSPHATE (SALT) 1G AT 0, 24, AND THEN 0.5 G AT 48 HOURS

HOURS CHLOROQ/ GR
- MEFLOQUINE,

0 1

24 1

48 0.5

~ 1 x 250 MG FOR 3 DAYS, OR 750-1250 MG, THEN 500 MG AFTER 6-8 HOURS

Day

250 mg I: 1000 MG

OR

7 HOUR

500 MG

TREATMENT OF ACUTE ATTACKS (2)

- QUININE SULFATE (PLUS DOXYCYCLINE, CLINDAMYCIN, OR FANSIDAR - ATOVAQUONE 250 MG (PLUS DOXYCYCLINE 100 MG OR PROGUANIL 100 MG) - HALOFANTRINE,

- ARTEMISININ (QINGHAOSU), FISRT DAY 2X2 TABS,

THEN 2X1 TABLET FOR 5 DAYS Day

2x1

2x1

2x1

2x1

Tablet

2x2

2x1

TREATMENT OF ACUTE ATTACKS (3) IN SEVERE PATIENTS

- START ORAL THERAPY WITH CHLOROQUINE

AS SOON AS POSSIBLE
- IV QUININE DIHYDROCHLORIDE - QUINIDINE GLUCONATE

- PARENTERAL CHLOROQUINE

TREATMENT OF ACUTE ATTACKS (4)

2. ERADICATION OF P. VIVAX OR P. OVALE

CHLOROQUINE AS ABOVE FOLLOWED BY 0.5 G ON DAYS 10

AND 17 PLUS PRIMAQUINE PHOSPHATE, 26,3 MG (SALT) DAILY FOR 14 DAYS STARTING ABOUT DAY 4 DAY

10

17

CHLOROQ/G
PRIMAQUINE

1.0

1.0

0.5

0.5

0.5

25/ 26.3 FOR 14 DAYS

TREATMENT OF ACUTE ATTACKS (5)

3. ELIMINATION OF PERSISTENT GAMETOCYTEMIA

- CHLOROQUINE FOR P.VIVAX, P. OVALE, P. MALARIAE - PRIMAQUINE SALT, SINGLE DOSE, 26.3 MG FOR P. FALCIPARUM

TREATMENT OF ACUTE ATTACKS (6)

* TREATMENT OF FALCIPARUM MALARIA ACQUIRED IN AREAS WHERE P. FALCIPARUM IS RESISTANT TO CHLOROQUINE (1) - START WITH ORAL QUININE SULFATE, 10 MG/KG 3X DAILY FOR 3-7 DAYS, PLUS :

~ DOXYCYCLINE, 2X100 MG FOR 7 DAYS

~ CLINDAMYCIN. 3X900 MG DAILY FOR 5 DAYS ~ PYRIMETHAMINE, 2X25 MG DAILY FOR 3 DAYS

~ SULFADIAZINE, 4X500 MG DAILY FOR 7 DAYS

~ 3 TABLETS OF FANSIDAR (PYRIMETHAMIN+ SULFADOXINE)

TREATMENT OF ACUTE ATTACKS (7)

P. FALCIPARUM IS RESISTANT TO CHLOROQUINE (2). - ALTERNATIVE DRUGS ARE: ~ MEFLOQUINE ~ HALOPHANTRINE ~ ARTESUNATE ~ ATOVAQUONE - SEVERELY ILL: ~ IV QUININE OR QUINIDINE ~ DOCYCYCLINE OR CLINDAMYCIN PARENTRALLY - ORAL TREATMENT WITH QUININE PLUS THE ANTIBIOTIC SHOULD BE AS SOON AS POSSIBLE

TREATMENT OF ACUTE ATTACKS (8)

* SPECIAL TREATMENT FOR TREATMENT OF SEVERE P. FALCIPARUM MALARIA (1) - MEDICAL EMERGENCY THAT REQUIRES: ~ HOSPITALIZATION ~ INTENSIVE CARE ~ IV CHEMOTHERAPY AS RAPID AS POSSIBLE ~ REQUIRING >48 HOUR OF PARENTRAL THERAPY ~ REDUCE THE QUININE OR QUINIDINE DOSE BY ONE-THIRD TO ONE-HALF ~ REHYDRATION SHOULD BE DONE WITH CAUTION ~ FLUID, ELECTROLYTE & ACID- BASE BALANCE MUST BE MONITORED

TREATMENT OF ACUTE ATTACKS (9) * SPECIAL TREATMENT FOR TREATMENT OF

SEVERE P. FALCIPARUM MALARIA (2):

~ EARLY DIALYSIS MAY BE NECESSARY FOR RENAL FAILURE

~ BLOOD GLUCOSE LEVELS SHOULD BE MONITORED

EVERY 6 HOURS IF HYPOGLYCEMIA +, ~ 50% DEXTROSE, 1-2 ML/KG ~ MAINTENANCE 5-10% DEXTROSE

TREATMENT OF ACUTE ATTACKS (10)

* SPECIAL TREATMENT FOR TREATMENT OF SEVERE P. FALCIPARUM MALARIA (3)

- DIC FRESH WHOLE BLOOD

- HCT < 20% TRANSFUSION - EXCHANGE TRANSFUSION WHEN >15% RBC

ARE PARASITIZED
- SEIZURES ANTICONVULSANTS - TEMPERATURE IS MAINTAINED <38.5 C - BLOOD FILM SHOULD BE CHECKED DAILY UNTIL PARASITEMIA CLEARS; WEEKLY THEREAFTER FOR 4 WEEKS RECRUDESCENCE?

B. CHEMOPROPHYLAXIX (1) a. IN REGIONS WHERE P. FALCIPARUM AND P. VIVAX ARE SENSITIVE TO CHLOROQUINE ~ DRUG OF CHOICE 1. CHLOROQUINE PHOSPHATE, 500 MG WEEKLY, ONE WEEK BEFORE ENTERING THE ENDEMIC AREA, WHILE THERE, AND FOR 4 WEEK AFTER LEAVING +/wks

Week 500 mg

1 +

1 +

2 +

3 +

4 +

CHEMOPROPHYLAXIX (2)
~ ALTERNATIVE DRUGS 1. HALOFANTRINE. 2. FANSIDAR 3. AMODIAQUINE.

4. PYRIMETHAMINE
5. ARTEMISININ 6. PROGUANIL 7. QUININE

CHEMOPROPHYLAXIX (3)
b. IN REGIONS WHERE P. FALCIPARUM IS RESISTANT

TO CHLOROQUININE
~ DRUGS OF CHOICE 1. MEFLOQUINE SALT, 250 MG (228 MG BASE) WEEKLY, 3 WEEKS BEFORE ENTERING THE ENDEMIC AREA, WHILE THERE, AND FOR 4 WEEKS AFTER LEAVING Week

250 mg

+/wks +

CHEMOPROPHYLAXIX (4)
~ ALTERNATIVE: - FIRST ALTERNATIVE: DOXYCYCLINE, 100 MG DAILY, 2 DAYS BEFORE ENTERING THE ENDEMIC AREA, WHILE THERE, AND FOR 4 WEEKS AFTER LEAVING

Day 1
100 mg +

week

+/day

CHEMOPROPHYLAXIX (4)
~ ALTERNATIVE: - SECOND ALTERNATIVE: MALARONE (ATOVAQUONE 250 MG + PROGUANIL 100 MG), ONE TABLET DAILY, ONE TABLET THE DAY BEFORE ENTERING THE

ENDEMIC AREA, WHILE THERE, AND FOR 1 WEEK

AFTER LEAVING Day 250 Malarone 100 Proguanil 1 + Day +/day 1 + 7 +

CHEMOPROPHYLAXIX (5)
- OTHER ALTERNATIVES: DAILY PROGUANIL 200 MG + WEEKLY CHLOROQUINE 0.5 G, MORE PROTECTION THAN CHLOROQUINE ALONE: Week 500 /Klrqn 1 + +/wks
PLUS

1 +

2 +

3 +

4 +

Day

200/ Prognl

1 +

7 +

+/day

1 +

7 +

CHEMOPROPHYLAXIX (6)
c. PROPHYLAXIS FOR PREGNANT WOMEN

- THE BEST COURSE IS WEEKLY CHLOROQUINE +/

PROGUANIL - IN AREAS OF CHLOROQUINE-RESISTANT MALARIA

MEFLOQUININE, EXCEPT IN THE FIRST TRIMESTER

- DRUGS CONTRAINDICATED ARE DOXYCYCLINE & PRIMAQUINE

PROGNOSIS
- UNCOMPLICATED & UNTREATED PRIMARY ATTACK OF P. VIVAX, P. OVALE, OR P. FALCIPARUM MALARIA USUALLY LASTS 2-4 WEEKS; P. MALARIAE ABOUT TWICE AS LONG. - WITH PROMPT ANTIMALARIAL THERAPY, THE PROGNOSIS IS GENERALLY GOOD, BUT IN P. FALCIPARUM INFECTIONS, WHEN SEVERE COMPLICATIONS DEVELOP, THE PROGNOSIS

IS POOR EVEN WITH TREATMENT