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Presentation

Managemen
Title
Subheading goes
t of Severe
here

Malaria
cases
Learning Overview

Trend in Severe Malaria

Challenges in Severe Malaria

Management

Severe Malaria Treatment

Specific Supportive Options

Case studies and Management


Recent Trend in
Severe Malaria
63% of P. vivax, 27% of P. falciparum
and 10%of mixed infections.

Vivax malaria can be as severe


as in falciparum malaria.
Vivax malaria could
not be considered
'benign' anymore

The spectrum and degree of


complications of vivax malaria was
similar to that of falciparum group.
J Vector Borne Dis 52, December 2015, pp. 281286
India contributes nearly half (46%) ,
China 19%, while Indonesia and Pakistan
together contribute 12% of the global
population at risk.
Half of world population is
at the risk for malaria

By 2015,
212 million new
cases of malaria

4,29,000 malaria
deaths

Malaria killed
3,03,000 under-
fives globally

Fact Sheet: World Malaria Report 2016


Estimated country share
for malaria, 2015

P. vivax malaria case


Total malaria cases

World malaria report


2016. WHO
More than 80% of malaria cases and
deaths occur in less than 20
countries

Malaria
cases Malaria
deaths

WHO Global Malaria Programme. WORLD MALARIA REPORT 2015


Monthly malaria cases
in India
(2012-2015)

In 2015, 1972 P. vivax, 223 P. falciparum


and 66 mixed malaria cases were
diagnosed for a total of 2261 annual malaria.
There is rise in P.vivax cases.
Chery et al. Malar J (2016) 1
Multiple Organ
Dysfunction in
Severe Malaria

All five Plasmodium species are able


to induce organ dysfunction due to a
particular inflammatory response.
Multiple Organ Dysfunction During Severe Malaria: The Role of the Inflammatory Response
2016.
http://dx.doi.org/10.5772/65348
Definations of
Severe Malaria
Severe falciparum malaria
Definition of severe malaria by 2015 WHO
guidelines
Severe falciparum malaria is defined as one or
more of the following, occurring in the absence of
an identified alternative cause and in the presence
of P. falciparum asexual parasitaemia.

Cerebral malaria/unarousable coma/Impaired


consciousness: A Glasgow coma score < 11 in
adults or a Blantyre coma score < 3 in children.

Renal impairment: Plasma or serum creatinine > 265


mol/L (3 mg/dL) or blood urea > 20 mmol/L.

Guidelines for the treatment of malaria 3rd


edition. WHO 2015
Severe falciparum malaria

Shock: Compensated shock is defined as capillary refill


3 s or temp gradient on leg (mid to proximal limb), but
no hypotension. Decompensated shock is defined as
systolic blood pressure < 70 mm Hg in children or < 80
mm Hg in adults, with evidence of impaired perfusion
(cool peripheries or prolonged capillary refill).

Multiple convulsions: More than two episodes within


24 h

Acidosis: A base deficit of > 8 mEq/L or, if not


available, a plasma bicarbonate level of < 15 mmol/L or
venous plasma lactate 5 mmol/L. Severe acidosis
manifests clinically as respiratory distress (rapid, deep,
laboured breathing).

Guidelines for the treatment of malaria 3rd


edition. WHO 2015
Severe falciparum malaria

Hypoglycaemia : Plasma glucose level of < 40 mg/dl


(2.2 mmol / l).

Prostration: Generalized weakness so that the


person is unable to sit, stand or walk without
assistance.

Severe malarial anaemia: Haemoglobin


concentration 5 g/dL or a haematocrit of 15% in
children < 12 years of age (< 7 g/dL and < 20%,
respectively, in adults) with a parasite count > 10
000/L.

Guidelines for the treatment of malaria 3rd


edition. WHO 2015
Severe falciparum malaria

Jaundice: Plasma or serum bilirubin > 50 mol/L (3


mg/dL) with a parasite count > 100 000/ L.

Pulmonary oedema: Radiologically confirmed or


oxygen saturation < 92% on room air with a respiratory
rate > 30/min, often with chest indrawing and
crepitations on auscultation.

Significant bleeding: Including recurrent or prolonged


bleeding from the nose, gums or venepuncture sites;
haematemesis or melaena

Hyperparasitaemia: P. falciparum parasitaemia > 10%.

Guidelines for the treatment of malaria 3rd


edition. WHO 2015
Severe vivax
malaria
The criteria for severe vivax malaria
are the same as for adults and
children with severe falciparum
malaria but with no parasitaemia
density thresholds (and without the
criterion of hyperparasitaemia).

There is a 4- to 5-fold greater loss of


uninfected red cells in P. vivax
infection relative to P. falciparum
infection at low parasite densities,
so P. vivax may cause severe
anaemia at lower parasitaemias.

2014 WHO. Tropical Medicine and International Health is published by John


Severe
manifestations of
malaria in adults
and children

2014 WHO. Tropical Medicine and International Health is published by John


Clinical approach to
the patient with
suspected severe
malaria
Microscopy is the gold standard

If not available

RDT should be used to diagnose


P.falciparum malaria

If not available
A blood smear is made and
treatment started on the basis of
the clinical suspicion of severe
malaria.

Guidelines for Establishing Sentinel Surveillance


Hospitals and Management of Severe Malaria
Cases. NVBDCP (2009)
Clinical approach to
the patient with
suspected severe
malaria
Microscopy Microscopy
and RDT and RDT

Negati Positiv Negati Negative


ve e ve

Such a patient
It is possible
should not be
that antigen is recorded as severe
persisting from malaria, but may be
an earlier treated as such, if
infection the treating
In children, febrile convulsions, physicianrepeated deems it
vomiting and dehydration are absolutely
common necessary.
if the
temperature is high from any cause. Therefore,
these symptoms are not necessarily indicative
of severe malaria Guidelines
in children.
for Establishing Sentinel Surveillance
Hospitals and Management of Severe Malaria
Cases. NVBDCP (2009)
Challenges in severe malaria

Difficulty in diagnosis

ACT monotherapy

Counterfeit antimalarials: 12% in one


pilot study
Quality of management: Time from
fever to diagnosis and treatment
Complications & mortality

Anvikar et al. Indian J Med Res.2014 Feb;


Management of
Severe Malaria
Considerations in
treatment of severe
malaria
Majority of deaths due to severe malaria
usually occur within 48 hours of
admission.

Critical care clinics. 2013 Oct 3


Initial management in
severe malaria

J Postgrad Med. 2004 Jan-Mar;50


Initial management in
severe malaria (Cont.)

J Postgrad Med. 2004 Jan-Mar;50


Chemotherapy of severe mal

Initial parenteral Follow-up


treatment for at treatment, when
least 48 hours: patient can take
oral medication
CHOOSE ONE of following
following four parenteral
options treatment

Quinine: 20mg
quinine salt/kg
body weight on
admission (IV Quinine 10 mg/kg
three times a day
infusion or divided
IM injection) with:
followed by doxycycline 100 mg
maintenance dose once a day or
of 10 mg/kg 8 clindamycin in
hourly; infusion rate pregnant women
should not exceed 5 and children under
mg/kg per hour. 8 years of age,
Loading dose of - to complete
Note: The parenteral treatment 7
in severe NVBDCP
2016
20mg/kg
malaria should
cases not
should be given for minimum of
24 hours once started
days of treatment.
Chemotherapy of severe
malaria (cont.)
Initial parenteral Follow-up
treatment for at treatment, when
least 48 hours: patient can take
oral medication
CHOOSE ONE of following
following four parenteral
options treatment
Artesunate: 2.4 mg/kg
i.v. or i.m. given on
admission (time=0), Full oral course of
then at 12 h and 24 h, Area-specific ACT:
then once a day. In NorthEastern
or states: Age-specific
Artemether: 3.2 ACT-AL for 3 days
mg/kg bw i.m. given on + PQ Single dose
admission then 1.6 on second day
mg/kg per day. In other states:
or Treat with: ACT-SP
Note: The parenteral treatment in days
for 3 severe
+malaria
PQ NVBDCP
Arteether: 150 mg
cases should be given for minimum of 24 hours 2016

once
dailystarted; Single
i.m for ACT-AL-Artemether
3 days in dose on
- Lumefantrine;
Specific
Supportive
Treatments in
Severe Malaria
Severe Malaria
Coma (Cerebral malaria)
Acute renal failure (ARF)
Severe anaemia
Jaundice
Shock/circulatory collapse
Hypoglycaemia
Pulmonary oedema/adult
respiratory distress syndrome
(ARDS)
Metabolic acidosis/acidaemia
Convulsions
Significant bleeding
Coma (Cerebral malaria)

An acute encephalopathy that


complicates exclusively by
Plasmodium falciparum

Cerebral malaria (CM) forms


part of the spectrum of severe
malaria, with a case fatality
rate ranging from 15% in
adults to 8.5% in children.
Motor posturing and possible se
Susceptible Population
Children and young adults
Pregnant women
AIDS

Severe opisthotonic (extensor) p


Lancet 376, 16471657 (201
Assessment of level
of coma
Modified Glasgow Coma Scale for adults
and children over 12yrs

Total score = Eye opening score + Verbal (intubated or n


* Total score may vary from 3-15. Unrousable coma refle
This scale should be used repeatedly to assess improvem

Guidelines for Establishing Sentinel Surveillance


Hospitals and Management of Severe Malaria
Cases. NVBDCP (2009)
Assessment of level
of coma
Blantyre Coma scale for children below
12 years

Guidelines for Establishing Sentinel Surveillance


Hospitals and Management of Severe Malaria
Cases. NVBDCP (2009)
ABC of Coma
Management
A. Airway
Maintain the airway by keeping it clean
Oral or oropharyngeal airway
Nasogastric tube to prevent aspiration pneumonia

B. Breathing
If tachypnoea, laboured respiration or acidotic
breathing is present,
patient may need oxygen inhalation and ventilatory
support.

C. Circulation
Check for dehydration by examining the pulse rate,
blood pressure, skin elasticity, jugular venous
pressure, moisture of the tongue, urinary volume
and colour.
If dehydration is present, infuse intravenous fluids.
Suspected infections must be treated with antibiotics

Guidelines for Establishing Sentinel Surveillance


Hospitals and Management of Severe Malaria
Cases. NVBDCP (2009)
Mechanical Nasogastric
ventilation aspiration
Nasogastric
feeding in an
unconscious
patient

Trop Med Int Health. 2014 Sep; 19 (s1 Suppl): 7-131


Alternative causes
of unrousable coma
in severe malaria

Patients having clinical


presentation of coma should
always be assessed for an
alternative cause of the reduced
level of consciousness.
Trop Med Int Health. 2014 Sep; 19 (s1 Suppl): 7-13
Severe Malaria
Coma (Cerebral malaria)
Acute renal failure (ARF)
Severe anaemia
Jaundice
Shock/circulatory collapse
Hypoglycaemia
Pulmonary oedema/adult
respiratory distress syndrome
(ARDS)
Metabolic acidosis/acidaemia
Convulsions
Significant bleeding
Acute renal failure (ARF)

Incidence of ARF in Malaria in India is 1%-


60% but mortality is high about 15-45%.

The vulnerable group of patients are:


pregnant women,
with high parasitaemia,
with jaundice,
with prolonged dehydration, or
patients receiving NSAIDs

Kanodia et al, 21(6); 2010;1088-1091


JIACM 2002; 3(2): 141-7
ARF symptoms and signs

Pak J Med Sci 2015 Vol. 31 No. 6


ARF Treatment

Management of severe malaria: A practical handbook; 3rd edition. World Health


Organization. 2012: 43-54.7
Trop Med Int Health. 2014 Sep; 19 (s1 Suppl): 7-131.
ARF Treatment (Cont.)

Management of severe malaria: A practical handbook; 3rd edition. World Health


Organization. 2012: 43-54.7
Trop Med Int Health. 2014 Sep; 19 (s1 Suppl): 7-131.
Peritoneal dialysis
in ARF

Trop Med Int Health. 2014 Sep; 19 (s1 Suppl): 7-131

Management of severe malaria: A practical handbook; 3rd edition. Wor


Severe Malaria
Coma (Cerebral malaria)
Acute renal failure (ARF)
Severe anaemia
Jaundice
Shock/circulatory collapse
Hypoglycaemia
Pulmonary oedema/adult
respiratory distress syndrome
(ARDS)
Metabolic acidosis/acidaemia
Convulsions
Significant bleeding
Severe anaemia

Severe anaemia
contributes 3-46% of
inpatient pediatric
fatalities.

The
pathophysiological
processes involve
direct and indirect
destruction of
parasitized and non-
parasitized RBCs,
inefficient and/or
suppression of
erythropoiesis, and
dyserythropoiesis.

Int. J. Biol. Sci. 2011


Management of severe anemia
in children

Calculation of transfusion volume:

Management of severe malaria: A practical handbook; 3rd edition. World Health


Organization. 2012: 23-42.
Management of children with less
severe anemia

Management of severe malaria: A practical handbook; 3rd


edition. World Health Organization. 2012: 23-42.
Management of adults
with severe anemia

Trop Med Int Health. 2014 Sep; 19 (s1 Su


Severe Malaria
Coma (Cerebral malaria)
Acute renal failure (ARF)
Severe anaemia
Jaundice
Shock/circulatory collapse
Hypoglycaemia
Pulmonary oedema/adult
respiratory distress syndrome
(ARDS)
Metabolic acidosis/acidaemia
Convulsions
Significant bleeding
Jaundice

Its incidence
varies between
11.5% to 62% in
epidemics

Association of
jaundice is 40%
and 9.09% with P.
falciparum and P.
vivax cases,
respectively

Journal of Gastroenterology and Hepatology (2005) 20, 13221332


Causes of jaundice in
malaria

Journal of Gastroenterology and Hepatology (2005) 20, 13221332


Severe Malaria
Coma (Cerebral malaria)
Acute renal failure (ARF)
Severe anaemia
Jaundice
Shock/circulatory collapse
Hypoglycaemia
Pulmonary oedema/adult
respiratory distress syndrome
(ARDS)
Metabolic acidosis/acidaemia
Convulsions
Significant bleeding
Shock/circulatory collapse
Patient can develop sudden hypotension and
become shocked (Algid Malaria).

Trop Med Int Health. 2014 Sep; 19 (s1 Su

Clinical Manifestations of Complicated Malaria An Over


Shock management

Management of severe malaria: A practical handbook; 3rd


edition. World Health Organization. 2012: 43-54
Shock management

Management of severe malaria: A practical handbook; 3rd


edition. World Health Organization. 2012: 43-54
Severe Malaria
Coma (Cerebral malaria)
Acute renal failure (ARF)
Severe anaemia
Jaundice
Shock/circulatory collapse
Hypoglycaemia
Pulmonary oedema/adult
respiratory distress syndrome
(ARDS)
Metabolic acidosis/acidaemia
Convulsions
Significant bleeding
Hypoglycaemia
Hypoglycaemia is a sign of poor prognosis with a
morality rate as high as 40%

Hypoglycaemia (blood glucose < 2.2mmol/l)


occurs in 3 groups of patients, which may
overlap:
Patients with severe disease, especially
young children;
Patients treated with quinine as a result of a
quinine-induced hyperinsulinaemia; and
Pregnant women, either on admission or
after quinine treatment

Management of severe malaria: A practical handbook 3rd ed. WHO 2012


Hypoglycaemia management

Management of severe malaria: A practical handbook; 3rd edition. World Health


Organization. 2012: 43-54.
Trop Med Int Health. 2014 Sep; 19 (s1 Suppl): 7-131.
Severe Malaria
Coma (Cerebral malaria)
Acute renal failure (ARF)
Severe anaemia
Jaundice
Shock/circulatory collapse
Hypoglycaemia
Pulmonary oedema/adult
respiratory distress syndrome
(ARDS)
Metabolic acidosis/acidaemia
Convulsions
Significant bleeding
Pulmonary oedema/adult
respiratory distress syndrome
(ARDS)
Almost 25% of adult
patients with severe
falciparum malaria develop
respiratory distress

High rate mortality over


Radiographic appearance of ARDS
80%

Fluid overload may give


rise to pulmonary edema.
It is difficult to differentiate
between both the
conditions and they may
also coexist in the same
patient. Acute pulmonary oedema developing
immediately after delivery in a patient

Management of severe malaria: A practical handbook; 3rd edition.


World Health Organization. 2012: 43-54.
Trop Med Int Health. 2014 Sep; 19 (s1 Suppl): 7-131.
Measurement of
hypoxemia in
respiratory distress
Patients presenting with hypoxemia
should receive oxygen to achieve an
oxygen saturation >90%, as soon as
possible

Trop Med Int Health. 2014 Sep; 19 (s1 Suppl): 7-13


Management of
pulmonary edema

Management of severe malaria: A practical handbook; 3rd


edition. World Health Organization. 2012: 43-54.
Management of
pulmonary edema
due to
overhydration

Management of severe malaria: A practical handbook; 3rd


edition. World Health Organization. 2012: 43-54.
Severe Malaria
Coma (Cerebral malaria)
Acute renal failure (ARF)
Severe anaemia
Jaundice
Shock/circulatory collapse
Hypoglycaemia
Pulmonary oedema/adult
respiratory distress syndrome
(ARDS)
Metabolic acidosis/acidaemia
Convulsions
Significant bleeding
Metabolic
acidosis/acidaemia
Arterial, venous, capillary, and CSF
concentration of lactate increases in
proportion to the severity

The acidosis is largely caused by the


accumulation of both lactic and 3-
hydroxybutyric acids with decreasing blood
glucose

JIACM 2003; 4(4): 323-31


Am. J. Trop. Med. Hyg., 77(2), 2007, pp. 256260
Acidosis Management

Management of severe malaria: A practical handbook; 3rd


edition. World Health Organization. 2012: 43-54.
Bicarbonate
infusion for
metabolic acidosis

Trop Med Int Health. 2014 Sep; 19 (s1 S


Severe Malaria
Coma (Cerebral malaria)
Acute renal failure (ARF)
Severe anaemia
Jaundice
Shock/circulatory collapse
Hypoglycaemia
Pulmonary oedema/adult
respiratory distress syndrome
(ARDS)
Metabolic acidosis/acidaemia
Convulsions
Significant bleeding
Convulsions
The National Institute of Health (NIH), defined a
febrile seizure as an event in infancy or childhood,
occurring between 3 months and 5 years of age,
associated with fever but without evidence of
intracranial infection or defined cause
Children with wasting presented mostly with
convulsions (73%)

Br. J. Pharmacol. Toxicol., 4(4): 128-135,


2013
The Open Area Studies Journal, 2011,
Volume 4
Management of Convulsions

Trop Med Int Health. 2014 Sep; 19 (s1 Suppl): 7-131.


Severe Malaria
Coma (Cerebral malaria)
Acute renal failure (ARF)
Severe anaemia
Jaundice
Shock/circulatory collapse
Hypoglycaemia
Pulmonary oedema/adult
respiratory distress syndrome
(ARDS)
Metabolic acidosis/acidaemia
Convulsions
Significant bleeding
Significant bleeding
In cases of bleeding disorders, clinical suspicion
for disseminated intravascular coagulation
(DIC) should be raised, as it indicates
concomitant bacterial sepsis.

Management of severe malaria: A practical handbook; 3rd


edition. World Health Organization. 2012: 43-54.
Trop Med Int Health. 2014 Sep; 19 (s1 Suppl): 7-131.
Case studies on
management of
severe malaria
CASE STUDY - 1
A woman from Punjab, aged 25 years, wife of
an officer in Assam Rifles is brought to a central
hospital at Dimapur (Nagaland). She is in the
seventh month of her first pregnancy.

The patient became ill five days ago, with


chills, sweating and headache. An antibiotic
was prescribed and her condition seemed to
improve, but yesterday she developed rigors
and persistent vomiting. A blood film at the
local clinical revealed malaria parasites, and
oral quinine (600 mg every 8 hours) was
prescribed. She took two doses.

Today she has been referred to a central


hospital because of restlessness and increasing
mental confusion.

Guidelines for Establishing Sentinel Surveillance Hospitals


and Management of Severe Malaria Cases. NVBDCP 2009.
CASE STUDY - 1
(Cont.)
Examination reveals:

A semiconscious woman, who is unable to

converse.
She withdrew her hand from a painful

stimulus.
No neck stiffness, jaundice, pallor or rash.

Axillary temperature is 39 C.

Pulse 90 beats/min.

Blood pressure 110/70 mm

Uterine fundus is palpable (26-28 weeks),

and
Foetal heartbeats can be heard.

Guidelines for Establishing Sentinel Surveillance Hospitals


and Management of Severe Malaria Cases. NVBDCP 2009.
Question 1.
What tests are
urgently required?
Blood glucose. Pregnant women are susceptible
to hypoglycaemia with any stress or infection.
They are particularly likely to develop
hypogycaemia during treatment with quinine. This
patient is pregnant, has already received quinine
and has altered consciousness. Hypoglycemia is
therefore, a strong possibility.

Haematocrit. Because she is pregnant she may


already be anaemic due to iron or folate
deficiency. Malaria may rapidly exacerbate
anemia. The risk of developing pulmonary oedema
is increased in patients with severe anaemia.

Parasite density.

Lumber puncture (where possible). Meningitis


may coexist with malaria.

Blood culture (where possible). Septicemia may


complicate severe malaria. In pregnancy there is
increased susceptibility to bacterial infections
e.g. pneumococcal infection

Guidelines for Establishing Sentinel Surveillance Hospitals and


Management of Severe Malaria Cases. NVBDCP 2009.
Question 2.
If the whole-blood glucose
is 1.2 mmol/L, what
treatment will you give?

50% dextrose, 20 ml by intravenous


injection.

As hypoglycaemia may recur and


can be severe in pregnancy, monitor
the blood glucose level frequently.

Guidelines for Establishing Sentinel Surveillance Hospitals and


Management of Severe Malaria Cases. NVBDCP 2009.
Question 3.
If the blood film shows
P.falciparum rings '++++', and
the CSF fluid is normal except
for low glucose, in that case:
a) What animalarial drugs will you administer and
by which route?
Quinine by i.v infusion. An alternative route for quinine
is i.m, but the intravenous route is preferable in a
centre where a drip can be set up.

b) Is there an alternative to quinine in the pregnant


woman?
As per WHO 2006, parenteral artesunate preparations
may safely be used in 2nd and 3rd trimesters of
pregnancy.

c) Would you give a loading dose of quinine?


A loading dose of quinine should not be given, because
the patient has received quinine within the last 24
hours, and a loading dose may therefore, lead to
dangerously high blood levels of the drug.

d) What nursing procedures are important during


this treatment?
An important nursing responsibility is the control of the
rate of infusion. If quinine is allowed to run too rapidly,
hypotension and hypoglycemia may develop. On the
other hand, if the infusion is too slow, inadequate blood
levels of the drug may be achieved.
Question 4.
After 6 hours, the patient becomes
increasingly restless. The respiratory
rate increases to 40/ minute. The
blood glucose level is normal. What
special observations would you
make?
Look for evidence of pulmonary oedema,
which may complicate falciparum malaria,
especially in pregnancy.

Review the urinary volumes passed, the


volumes of intravenous fluid given and the
fluid balance.

Assess the central venous pressure


(clinically or, if possible, with the help of a
central venous pressure line).

Examine carefully for gallop rhythm, basal


crepitations and hepatic enlargement.

Guidelines for Establishing Sentinel Surveillance Hospitals and


Management of Severe Malaria Cases. NVBDCP 2009.
Question 5.
What other observations are
particularly important in
this patient?

Foetal heart rate. Foetal distress is common


in malaria, especially if there is high fever.
Assisted vaginal delivery or even Caesarian
section must be considered if foetal distress is
severe.

Question 6.
What is the first question
that you would ask this
patient's relatives?

Ask about travel history- when had she


visited parts of the country where
transmission of malaria occurs? Had she
received a blood transfusion in the recent part
(an alternative source of malarial infection).

Guidelines for Establishing Sentinel Surveillance Hospitals and


Management of Severe Malaria Cases. NVBDCP 2009.
CASE STUDY- 2
In PHC Borda, District Kalahandi, Orissa,
various antimalarial drugs are available, but
intravenous infusions cannot be given.

A child aged 20 months became feverish two


days ago and has vomited several times today.
One hour ago the child had a convulsion,
described by the mother as a repetitive
twitching of limbs and mouth, followed by
unresponsiveness for a few minutes.

The child is now febrile, fully conscious, and


able to localize and respond to a painful
stimulus. A thick blood film shows P. falciparum
rings '++++'. The child repeatedly vomits any
antimalarial drug given by mouth.
Guidelines for Establishing Sentinel Surveillance Hospitals
and Management of Severe Malaria Cases. NVBDCP 2009.
Question 1.
Does the child have
cerebral malaria?
The fact that the child is now fully
conscious suggests that the convulsion was
a 'febrile convulsion' rather than a
component of cerebral malaria.
Convulsions occur in cerebral malaria but
they are not followed by rapid recovery of
consciousness.

a) What should you do about the


convulsions?
Make sure that the risk of further
convulsions is minimized by reducing the
child's temperature by pararcetamol, tepid
sponging, fanning, etc.

Guidelines for Establishing Sentinel Surveillance Hospitals and


Management of Severe Malaria Cases. NVBDCP 2009.
Question 2.
The district hospital is 30
km away and the journey
will probably take several
hours by bus
a) Should the patient be referred to hospital?
The decision to refer the patient will depend on
facilities available at the health centre. This child
needs antimalarial drugs and fluids, and should
receive them at a centre where they are
available.

b) What treatment would you give in the


meanwhile?
Because the child is persistently vomiting, the
first dose of antimalarial drug should be given
parenterally. Ideally, this should be by slow
intravenous infusion, but since this is not possible
in this facility in this case, it may be given by
intramuscular injection: quinine (10 mg salt /
kg).

Guidelines for Establishing Sentinel Surveillance Hospitals and


Management of Severe Malaria Cases. NVBDCP 2009.
Question 3.
The child successfully took the
second and third doses of
quinine by mouth and was
brought back to the clinic
the next day; there had been
little change; the child was
still febrile and the
parasitaemia was similar to
the previous day. Does this
suggest that the child has
drug-resistant malaria?

Fever commonly persists, and degree of


parasitaemia may remain same for up to
24 hours after the start of treatment,
even if the parasite is fully sensitive to
the drug being given.
By 48 hours, however, the density of
parasitaemia should be greatly reduced
and the condition of the patient
improves.
Guidelines for Establishing Sentinel Surveillance Hospitals and
Management of Severe Malaria Cases. NVBDCP 2009.
CASE STUDY- 3
The patient, a 28 year old male from
Chandrapur District of Maharashtra was posted
in Ladakh for five years. He returned home last
month.

One week ago he developed fever. He decided


this could not be malaria because he had grown
up in a malarious area and believed he was
therefore immune. Two days ago he became
confused, especially at night. He stayed in bed
and was attended by a servant who today
called the doctor because the patient was
increasingly confused. The last urine he had
passed was a small volume of very dark fluid 24
hours ago.

Guidelines for Establishing Sentinel Surveillance Hospitals


and Management of Severe Malaria Cases. NVBDCP 2009.
CASE STUDY- 3 (Cont.)
On examination:

The patient was a well nourished adult

man.

He was afebrile (rectal temperature 36.50

C).

He was restless but could make brief

appropriate answers to questions, and

localize the site of painful stimuli.

He was jaundiced and his mucous

membrane was pale.

Bleeding from the gums and,

Few retinal haemorrhages in the eyes.

Guidelines for Establishing Sentinel Surveillance Hospitals


and Management of Severe Malaria Cases. NVBDCP 2009.
Question 1.
What is the
differential
diagnosis?
Consider all diseases that may lead to
encephalopathy with jaundice: i.e. fulminant
hepatitis. Yellow fever, viral fevers, relapsing
fever, septicaemia, leptospirosis, alcoholism,
sickle cell crisis, etc.
Nevertheless, under the circumstances if the
patient is not able to pass urine, severe falciparum
malaria may be the most likely diagnosis.
Retinal haemorrhages are common in severe
malaria, and do not on their own indicate the
presence of abnormal bleeding tendency.

a) Was the patient right to think he was


immune to malaria?
No. Immunity to malaria is partial, and may be
almost completely lost if the patient doesn't stay
in endemic area for a few years.

Guidelines for Establishing Sentinel Surveillance Hospitals and


Management of Severe Malaria Cases. NVBDCP 2009.
Question 2.
The thick blood film shows
P.falciparum '++++' and the thin
blood film shows that 26% of red
cells are parasitized
a) What else would you look for in the thin blood film?
Platelets. Thrombocytopaenia is usual in falciparum
malaria but may be particularly severe in this patient who
has signs of bleeding tendency. Severe thrombocytopaenia
may be evident on a thin blood film.

b) What other tests would you carry out to investigate


the bleeding tendency?
Platelet count and prothrombin time. If possible it would be
useful to know the plasma fibrinogen and fibrin
degradation products. If the platelet count and plasma
fibrinogen are very low in a patient with spontaneous
bleeding, the bleeding can be attributed to disseminated
intravascular coagulation (DIC). However, if only the thin
blood film can be done, the scantiness of platelets in the
presence of bleeding in a patient with malaria suggests
DIC. The best bedside test for the presence of abnormal
bleeding due to DIC is the bleeding time. In this patient,
this is likely to be prolonged, since there is abnormal
bleeding spontaneously from the gums. A record of
bleeding time would be useful in order to monitor progress
in response to treatment.

Guidelines for Establishing Sentinel Surveillance Hospitals and


Question 2.
The thick blood film shows
P.falciparum '++++' and the thin
blood film shows that 26% of red cells
are parasitized (Cont.)

c) What treatment is needed for the


bleeding?
Fresh blood transfusion and alternatively,
platelet-rich plasma. Vitamin K is not helpful
since the bleeding is not due to vitamin K
deficiency. This patient may need blood
transfusion for malarial anaemia also.

Guidelines for Establishing Sentinel Surveillance Hospitals and


Question 3.
The patient has not passed
urine for 24 hours. What
investigations and actions are
appropriate?
Palpate the abdomen to see if the bladder is
distended. Try to get the patient to pass urine;
if he cannot, catheterize with full sterile
precautions and record urine volumes.
Do routine examination of urine and if possible,
for sodium concentration and specific gravity
also.
Correct any under-hydration by careful saline
infusion (urine specific gravity > 1. 015 and
sodium < 20 mmol/L suggests dehydration),
and if necessary, use drugs such as furosemide
and dopamine for proper flow of urine.
Measure plasma urea, creatinine and
electrolytes if possible; and electrocardiograph
helps to demonstrate hyperkalaemia.
If acute tubular necrosis gets established,
intensive care is required, with peritoneal
dialysis or haemodialysis.

Guidelines for Establishing Sentinel Surveillance Hospitals and


Management of Severe Malaria Cases. NVBDCP 2009.
Question 4.
15 ml of dark brown urine was
obtained by catheter. The urine
examination revealed albumin '++',
blood '+++', conjugated bilirubin '+
+' and urobilinogen '++'. Microscopy
of the urine showed no cells and a
few casts. How do you interpret the
results of the urine test?
The presence of blood in the urine (i.e.
haemoglobin) in the absence of red
blood cells indicates that there is free
haemoglobin in the urine, as a result of
intravascular haemolysis, a complication
of severe falciparum malaria.
Bilirubinuria indicates that there is some
increase in the conjugated
hyperbilirubinaemia, as in haemolysis.
Proteinuria is usual in the presence of
acute tabular necrosis, which is the
commonest of renal failure to
complicate
Guidelinesfalciparum malaria.
for Establishing Sentinel Surveillance Hospitals and
Management of Severe Malaria Cases. NVBDCP 2009.
Question 5.
Acute renal failure is
confirmed. Is it
possible that the
kidneys may recover?
Yes, in acute tubular necrosis, recovery
commonly takes place within a period of
few weeks.
It is therefore important to keep the
patient alive, if possible, by dialysis
(usually peritoneal dialysis) - because full
recovery is then likely, without the need
for continued long term dialysis

How should quinine therapy be given


to this patient with acute renal
failure?
If acute renal failure is confirmed, the first
dose of quinine should be the same as in
any other patient with severe malaria,
the dose should be reduced by 50% from
the third day onwards.
Severe Malaria at
a Glance..

Management of severe malaria: A practical handbook; 3rd edition. World Health


Organization. 2012: 43-54.
Trop Med Int Health. 2014 Sep; 19 (s1 Suppl): 7-131.
Severe Malaria at
a Glance..

Management of severe malaria: A practical handbook; 3rd edition. World Health


Organization. 2012: 43-54.
Trop Med Int Health. 2014 Sep; 19 (s1 Suppl): 7-131.
Thrombocytopa
enia: Can it be
considered
severe malaria?
JMSCR Jan 2017; 5(1)

Frequency of Various Complication

Thrombocyt
openia was
the most
frequent
complicatio
n in the
severe
cases.
ytopaenia is the MOST FREQUENT malaria-a

ologic alteration observed with all five Plasm

parasites causing disease in humans.

ough not included in the WHO criteria for se

arum malaria, severe thrombocytopaenia ha

y mentioned as an indicator of P. vivax malar

Antinori et al. Malar J (2016)


Malaria-triggered
thrombocytopenia

During malaria,
thrombocytopenia
is associated with
the binding of
parasite antigens
to the surface of
platelets to which
antimalarial
antibodies also
bind, leading to
the formation of
immune
complexes

Mem Inst Oswaldo Cruz, Rio de Janeiro, Vol. 106(Suppl. I): 52-63, 2011
Drawbacks in treatment
of thrombocytopenia
The immunosuppressant effect of
corticosteroids might mask the severity
of the underlying condition and increase
the viremic load by virtue of its
immunosuppressive property.

Thrombopoietin (TPO) receptor


agonists and mimetics like Eltrombopag
and Romiplastim are costly and
accessibility factors would hamper larger
proportion of people from availing them
and also they are associated with adverse
effects.

There is no specific anti-viral treatment


available at this point of time

A. C. Gowda. Indian Medical Gazette, MARCH 2015; 109-116


Cari
ca
pap
aya
leaf
extr
act
in
thro
mboc
ytope
nia

Better
&
viable Decre
Palata
option ases
ble Cost
in
and Fewer the effecti Averti
fever
appro side cost ve ng the
associ
priatel effect of and mortal
ated
y s hospit acces ities
with
formul alizati sible
throm
ated on
bocyt
openi
a

A. C. Gowda. Indian Medical Gazette, MARCH 2015; 109-116


Thank you