malaria - a dynamic disease · • examination of peripheral smear= species of parasite + level of...
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MALARIAA DYNAMIC DISEASE
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Parasite species
• Sub- Saharan Africa- >90%= Plasmodium Falciparum
• Rest= P. Ovale, P. Vivax, P. Malariae• Sometimes =mixed infections• P. Falciparum= may be severe +
complicated ----1.delay in treatment2.ineffective therapy.3.underdosing
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RISK GROUPS
• Almost all S.A = non-immune• Immunity acquired after lon term repeated
infection – eg- Mozambique, Malawi, Tanzania• HIGH RISK GROUPS-non- immune travellers,
residents in endemic areas of S.A, pregnant women, young children, splenectomy, immunocompromised.
• H.I.V + MALARIA- increase in clinical attacks + higher parasitaemia in Uganda. In S.A higher risk of severe malaria.
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CLINICAL PRESENTATION
• 7 days post exposure, average = 10- 21 days after mosquito bite
• Longer incubation if on chemoprophlaxsis or selected antibiotics
• 6-18 months have been recorded• P.Vivax, P. Malariae, P. Ovale can take up
to 1 year b4 first manifestation.
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INDEX OF SUSPICION
• MALARIA AREAS-North Eastern Kwazulu Natal, low altitude areas of Mpumalanga, Limpopo.
• Endemic in all sub-saharan countries except Lesotho.
• Seasonal peaks. In S.A – Oct to May.
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SYMPTOMS
• Fever is most common• “flu like” symptoms• Rigors, headaches, sweating, tiredness,
myalgia, abdominal pain, diarrhoea, LOA, nausea, vomiting, cough
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• In a febrile pt in S.A, where there is no obvious cause of fever and a recent history of visiting or living in a malaria area is not forthcoming , malaria should be excluded because mosquitos have been documented to travel.
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DIFFERENTIAL DIAGNOSIS
• Influenza• Hepatitis• Meningitis• Septicaemia• Typhoid• Tick bite fever• Gastroenteritis• Viral haem fever• HIV seroconversion
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LAB. DIAGNOSIS
• Blood test for parasites should be done .irrespective of time of year ,area or chemoprophylaxis.
• Majority of malaria cases= reveal parasite.• But NEGATIVE SMEAR does not exclude
diagnosis.Repeat specimens should be examined regularly and urgently until diagnosis confirmed, pt recovers or another diagnosis.
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• Examination of peripheral smear= species of parasite + level of parasitaemia.
• High levels of parasites ( >5% or >3+) = SEVERE MALARIA
• however severe disease may show low parasites. • Commercial kits for rapid diagnosis- detect
parasite antigen histidine rich protein 2. = highly sensitive. But dependent on correct usage + interpretation.should be used for acute malaria only. May be negative early. False + = S.L.E.
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• If diagnosis of malaria cant be made, decision to start treatment based on
1. Clinical grounds2.possible exposure to malaria parasite.3.severity of clinical picture
# sometimes pts with severe have negative smear due to sequestration of parsitised RBC’s.
# Thrombocytopaenia is a common finding.
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DIAGNOSIS MADE
• Malaria is a notifiable disease.
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TREATMENT- Objectives
1. Prevention of mortality2. Preventions of complications3. Elimination of parasitaemia to minimise
transmission4. Limit the emergence + spread of drug
resistance.
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RESISTANCE
• In S.A- Chloroquine resistance first in KZN, then in Mpumalaga.
• 1988- KZN – changed to sulfadoxine-pyrimethamine. Mpumalanga and Limpopo Provinces in 1997.
• Significant resistance to S.P in KZN- in 2001-changed to ARTEMETHER LUMEFANTRINE as first line.
• Advantages= combination drug, improved therapeutic response, potential decrease in transmission ., cost effective.
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CHOICE OF CHEMOTHERAPY
• SEVERITY OF DISEASE• RESISTANT PATTERN IN THAT AREA• SPECIES OF PARASITE• AGE, PREGNANCY, CO-MORBIDITY,
ALLERGIES, OTHER MEDS• PRESENCE OF VOMITING
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FEATURES OF SEVERE MALARIA
• CLINICAL FEATURES-1.impaired consciousness, convulsions2.respiratory distress3.jaundice4.bleeding5.shock
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• BIOCHEMICAL1.renal impairment- Cr >265 or rapid rise2.acidosis- HCO3 < 15, Lactate > 53.hepatic impairment- ALT>3X4. hypoglycaemia < 2.25.hypoxia pO2 < 8
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• HAEMATOLOGICAL:1. Parasitaemia > 5% or > 3+2.Hb < 6 or Hct <20%3.>5% neutrophils contain malaria pig.4.schizonts of P. falciparum in smear5. D.I.C
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TREATMENT- uncomplicated
# Artemether + Lumefantrine- < 65kg#Quinine + doxycycline/ clindamycin#Mpumalnga + Limpopo = Sulfadoxine-
pyrimethamine. BUT soon S.P +artesunate.
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TREATMENT-COMPLICATED
• IV Quinine + doxycycline/ clindaycin• P.Ovale or Vivax= chloroquine +
primaquine• P. Malariae= chloroquine• If unsure of species treat for P.falciparum.
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GENERAL MEASURES
• Adequate fluids + antipyretics• Monitor mental state, respiratory rate +
urine output.• Easy to underestimate severity• Complications may arise despite correct
treatment.• Clinical response 24 to 48 hours but fever
may last for 5 days.
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• Repeat peripheral smear after 72hrs treatment- decrese of > 75% of initial parasite count.
• Drug resistance should be considered if clinical or parasitological response = poor.
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ARTEMETHER LUMEFANTRINE
• Artemisinin derivative• Clear parasite mot rapidly from peripheral smear,
have favourable safety profile and may reduce malaria transmission by decreasing gametocyte development.
• Effective for uncomplicated P. falciparum + blood stage P. vivax
• Severe malaria only parenteral = effective. In S.A= ARTEETHER= oil based , given I.M
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• ARTEMETHER 20mg + LUMERFANTRINE 120mg
• only <65kg• C/I in pregnancy.• Absorption is critically dependant on co-
administration with food containing milk or fat.• S/E= GIT, sleep dist., palpitations, myalgia,
dizziness.
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POINTS TO REMEMBER1. NEED SUSPICION2. UNCOMPLICATED OR SEVERE3. EFFECTIVE TREATMENT-
ARTEMETHER LUMEFANTRINE /QUININE
4. NOTIFIABLE DISEASE5. CLINICAL + PARASITIOLOGICAL
RESPONSE.
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