MALARIA

Dr. Jalal
IMS/MSU

OBJECTIVES
Epidemiology and the life cycle of malaria.
Clinical presentation and complications.
Why hypoglycemia?
Why anemia?
Why dark urine? (black water fever)
Diagnosis of malaria
Treatment?
Treatment during pregnancy?
Prevention & Chemoprophylaxis?

2000

12,705 cases ( 0. 55 per 1,000 population)


2012

4,725 cases in (0.16 per 1,000 populations )


P. vivax 50.2%
P. falciparum 30.7%
P. malariae 16.7%
mixed infection 2.2%.

Malaysian Figure
Plasmodium Complications
Schffner's
Dots
Stages on
Smear
Relapse
Hypnozoites Antimalarial Resistance


P. falciparum


10
6



Coma (cerebral malaria)


Absent


Rings, occasional
gametocytes


No


Chloroquine, mefloquine,
halofantrine,
pyrimethamine-
sulfadoxine, plus partial
resistance to quinine and
quinidine
Hypoglycemia
Pulmonary edema, renal failure
Severe malarial anemia (<5 g
Hgb/dL)
P. vivax 25,000 Late splenic rupture (23 mo) Present All stages Yes Chloroquine
P. ovale 25,000 Present All stages Yes None known
P. Malariae 10,000 Immune complex nephrotic
syndrome
Absent All stages No None known
DIAGNOSIS OF MALARIA
History & PE

Blood smear (Microscopical)
Thick
Thin

Other blood investigations

Immunology & PCR (DNA of Parasite)
CHLOROQUINE-RESISTANT P. FALCIPARUM
PO quinine 650 mg quinine sulfate q8h 37 days
plus
PO doxycycline (Vibramycin)

or plus
100 mg bid 7 days
PO tetracycline 250 mg qid 7 days

or plus

PO clindamycin 20 mg/kg/day in 3 doses 7 days
Or plus
PO atovaquone 1000 mg/day atovaquone (2 Malarone tablets bid) 3 days
Proguanil (Malarone) 400 mg/day proguanil (2 Malarone tablets per day) 3 days
or
PO mefloquine
[*]
15 mg base/kg (750 mg), followed by 10 mg base/kg 500 mg (500 mg)
in 812 hr. Can also be given as a single 1250-mg dose, though less
well tolerated
or
PO artesunate
[]
4 mg/kg/day 3 days
[]

plus
PO mefloquine 25 mg base/kg (750 mg), followed by 10 mg base/kg 500 mg (500 mg)
in 812 hr

PO lumefantine plus artemether
(Coartem)
[]


80 mg artemether and 480 mg lumefantrine (4 tablets) at 0 and 8 hr on
day 1, followed by the same doses at 0 and 8 hr on days 2 and 3 (total
dose of 24 tablets for adults containing a total of 480 mg artemether
and 2880 mg lumefantrine over the course)
FOR PATIENTS UNABLE TO TOLERATE ORAL MEDICATIONS
quinidine 6.25 mg base/kg (10 mg gluconate salt/kg, up to a maximum of 600 mg salt) in
normal saline over 1- to 2-hr period, followed by 0.125 mg base/kg (0.02 mg
gluconate salt/kg)/min until parasitemia is <1% or the patient tolerates oral
medications
or
IV quinine 16.7 mg/kg base (20 mg dihydrochloride salt/kg) loading dose in D
5
W over 4-hr
period, followed by 8.3 mg base/kg (10 mg/kg dihydrochloride salt/kg) over 2- to
4-hr period, with the maintenance dose repeated q8h until the patient tolerates
oral medications. Maximum daily dose, 1800 mg dihydrochloride salt/day
or
IM quinine 8.3 mg base/kg (10 mg dihydrochloride salt/kg) q8h until able to take oral
medications; may begin with 16.7 mg base/kg (20 mg quinine dihydrochloride
salt/kg) loading dose. Divide the dose in half, and administer both into the
thighs, not the buttock
FOR PATIENTS ABLE TO TAKE ORAL MEDICATIONS
PO chloroquine
[]
10 mg base/kg = 600 mg base, followed by
an additional 5 mg base/kg (maximum, 300
mg base) after 6, 24, and 48 hr (1500 mg
base total = 2500 mg chloroquine phosphate
salt)
FOR PATIENTS UNABLE TO TAKE ORAL MEDICATIONS
IM chloroquine 2.5 mg base/kg IM q4h or 3.5 mg/kg q6h
(total dose not to exceed 25 mg/kg base)
IV chloroquine 10 mg base/kg over 4-hr period, followed by
5 mg/kg base q12h (given in a 2-hr infusion;
total dose not to exceed 25 mg base/kg)
TO PREVENT RELAPSE OF P. VIVAX OR P. OVALE INFECTION
PO primaquine
[]
30 mg primaquine base (26.3 mg
primaquine phosphate) daily 14 days
Prevention Of Malaria
Vector control (Insecticide spray )

Insecticidal treated bed net

Electronic Mosquito repellent (Not effective)

Intermittent Repeated Therapy (IRT) children/ pregnancy

Chemoprophylaxis

Vaccination (Still under research)