1. Affan Ali Roll No. 36CASE STUDY

2. Demographics Name: Muhammad Ali Age: 21 Years Gender: Male Marital Status: Un Married Ward: Medicine Hospital: Dow University Hospital 3. History No Disease History Not on Medication 4. Present Complains Morning & Midnight High Grade Fever for 5days Chills for 5days Vomiting for 1 day Epigastric Pain Sweating Weakness 5. Laboratory Findings Haemoglobin 11.3g/dl RBCs 3.7 x108/lMCV 93 flMCH 31 pgMCHC 33%PCV 34% 6. Laboratory Findings Total Leukocytes 3.1 x103/l Neutrophils 29%Eosinophils 1%Basophils 0%Monocytes 11%Lymphocytes 59%Platelets 95 x103/l 7. Laboratory Findings Sodium 140 mEq/lPotassium 3.4 mEq/lChloride 105 mEq/lBicarbonate 29 mEq/l Urea 42.4mg/dlSr. Creatinine 0.9 mg/dl 8. Laboratory Findings Dengue IgGP. FalciparumP. MixTyphi DotNegativeNegativePositiveNegative 9. Diagnosis 10. PRESCRIPTION 11. Ceftriaxone 12. Artemether/ Lumefantrine 13. Omeprazole 14. Metoclopramide 15. Acetaminophen 16. Vitamin B Complex 17. Others Dextrose Saline @ 100cc/hour Normal Saline @ 100 cc/hour 18. JUSTIFICATIONS 19. Ceftriaxone Prescribed for Prophylaxis of Hospital Acquired Infections Dose is Accurate (1- 4gm daily A/C severity) Frequency is appropriate (BD) Route is appropriate (IV) No Interaction with other Prescribed Drugs 20. Artemether/Lumefantrine Prescribed for Treatment of Malaria Dose is Accurate (80/480mg) Frequency is appropriate Route is appropriate (Oral) No Interaction with other Prescribed Drugs 21. Omeprazole Prescribed for Prophylaxis of Bed ridden ulcer Dose is Accurate (40mg) Frequency is appropriate (OD) Route is appropriate (IV) No Interaction with other Prescribed Drugs 22. Metoclopramide Prescribed for Treating vomiting Dose is Accurate (10mg) Frequency is appropriate (q8h) Route is appropriate (IV) Increases Rate of Absorption of Acetaminophen 23. Acetaminophen Prescribed for Treating Fever, Pain etc Dose is Accurate (1gm) Frequency is appropriate (q4 6hrs) Route is appropriate (IV) Rate of Absorption is increased by Metoclopramide 24. Vitamin B Complex Riboflavin (Vitamin B2):100mg Thiamine HCl (Vitamin B1):100mg, Cyanocobalamin:50mcgPrescribed for treating anemia Dose is Accurate Frequency is appropriate Route is appropriate No Interaction with other Prescribed Drugs 25. THE DISEASE 26. Malaria Malaria, one of the most widespread diseases, caused by Plasmodium SpeciesTransmitted by infected individuals via Mosquito Bite Blood transfusion, Congenitally, Infected needles by drug abusers 27. Types & Causative Agents 28. SYMPTOMS29 29. Life Cycle of Plasmodium Two interdependent life cycles Sexual cycle: occurs in the mosquitoAsexual cycle: occurs in the human Exo erythrocytic Phase Erythrocytic Phase30 30. Life Cycle of Plasmodium31 31. TREATMENT 32. MALIGNANT MALARIA 33. Quinine Adult Oral Dose 600mg q 8 hrs for 5 7 days with or followed by Doxycycline 200mg OD for 7days Or Clindamycin 450mg q 8 hrs for 7days Or if parasite is likely to be resistant Pyrimethamine 75mg / sulfadoxine 1.5g as a single dose 34. Quinine Pediatric Dose Oral 10mg/kg (Max 600mg) q 8 hrs for 7 days with or followed by Clindamycin 7 13 mg/kg (Max 450mg) q 8 hrs for 7days Or Over 12 years Doxycycline 200mg OD for 7days Or if parasite is likely to be resistant use pyrimethamine & sulfadoxine combination AgeDose< 4 yearsPyrimethamine 12.5mg / sulfadoxine 250mg56Pyrimethamine 25mg / sulfadoxine 500mg79Pyrimethamine 37.5mg / sulfadoxine 750mg10 - 14Pyrimethamine 50mg / sulfadoxine 1g 35. Quinine Adult Parenteral Dose Loading Dose 20mg/kg (Max 1.4gm) infused IV for 4 hours every 8 hours Maintenance Dose 10mg/kg (max 700mg) infused IV for 4 hours every 8 hoursPedriatric Dose Parenteral Same as Adult adjusted according to weight 36. Alternative Treatment Atovaquone / Proguanil Artemether / Lumefantrine 37. Atovaquone / Proguanil Adult Oral Dose 4 Standard Tablets Once Daily for 3 days A standard tablet contains 100 mg of proguanil hydrochloride and 250 mg of atovaquone 38. Atovaquone / Proguanil Pediatric Oral Dose Body WeightDose> 40 kgSame as Adult Dose5 8 kg2 Pediatric Tablets OD for 3 days9 10 kg3 Pediatric Tablets OD for 3 days11 20 kg1 Standard Tablet OD for 3 days21 30 kg2 Standard Tablet OD for 3 days31 40 kg3 Standard Tablet OD for 3 daysA pediatric tablet contains 25 mg of proguanil hydrochloride and 62.5 mg of atovaquone 39. Artemether / Lumefantrine Adult Oral Dose 4 Standard Tablets initially followed by 5 more same doses at 8, 24, 36, 48 & 60 hours A standard tablet contains 20 mg of Artemether and 120 mg of Lumefantrine 40. Artemether / Lumefantrine Pediatric Dose OralBody WeightDose> 35 kg (> 12yrs)Same as Adult Dose5 15 kg1 Tablet followed by 5 more doses at 8, 24, 36, 48 & 60 hours15 25 kg2 Tablet followed by 5 more doses at 8, 24, 36, 48 & 60 hours25 35 kg3 Tablet followed by 5 more doses at 8, 24, 36, 48 & 60 hoursA standard tablet contains 20 mg of Artemether and 120 mg of Lumefantrine 41. Pregnanacy Falciparum Malaria is dangerous in Pregnancy specially in last trimester Following are Safe Quinine Clindamycin Following should be avoided Doxycycline Atovaquone / Proguanil Artemether / Lumefantrine 42. Chloroquine is drug of choice in Benign MalariaBENIGN MALARIA 43. Chloroquine The adult dosage regimen for chloroquine by mouth is: initial dose of 620 mg then a single dose of 310 mg after 6 to 8 hours then a single dose of 310 mg daily for 2 days (approximate total cumulative dose of 25 mg/kg) 44. Primaquine It is used for Radical Cure (Prevent Relapse) in the case of P. vivax & P. ovale P. malariae Not required P. vivax 30 mg daily for 14 days following chloroquineP. ovale 15 mg daily for 14 days following 45. Chloroquine in Pediatrics The dosage regimen is: initial dose of 10 mg/kg (max. 620 mg) then a single dose of 5 mg/kg (max. 310 mg) after 68 hours then a single dose of 5 mg/kg (max. 310 mg) daily for 2 days 46. Primaquine in Pediatrics Should not be given to children under 6 months without specialist advice P. vivax 500mcg / kg (Max 30 mg) daily for 14 days following chloroquine P. ovale 250mcg / kg (Max 15 mg) daily for 14 days following chloroquine 47. Parenteral for Adult & Pediatrics IV infusion of Quinine 10mg / kg (Max 700mg) for 4 hours every 8 hours 48. Pregnancy Chloroquine is safe Primaquine should be avoided instead chloroquine should be continued at a dose of 310 mg each week during the pregnancy. 49. Chloroquine-resistant benign malaria We use, Quinine Atovaquone / Proguanil Artemether / Lumefantrine 50. Prevention Avoid Mosquito Bite Preventive Medicine Varies area to area In our region Chemoprophylaxis is not recommended 51. References BNF 61 www.cdc.gov/malaria www.who.int/topics/malaria