PRESENTATION PRESENTATION

By DR. Ramesh By DR. Ramesh BhargavaBhargava

Mr. R aged 17 yrs, Male admitted to my HOSPITAL ON 3/08/2008 with H/O High Grade Fever, Vomiting, Loose Motions & Breathlessness for Last 8 days

O/E S/E

P.120 per min A/S- ABD SOFTBP 100/70R-34/M LIVER - JPT-102 F SPLEEN – JP JVPNR NO-F.F.ICTERUS +

CYANOSIS ABSENT CLUBBING ABSENT R/S B/L CLEAR

NOACCOEDEMA ABSENT CVS. FAINT SYSTOLIC MUMER

TONGUE - DRY CNS – CLINICALLY NADMILD DEHYDRATION +

ON INVESTIGATION ON INVESTIGATION 1.CBP- Hb 6 gm %1.CBP- Hb 6 gm % TWBC- 11,200TWBC- 11,200 P- 64%P- 64% L- 30%L- 30% M- 3%M- 3% E- 3% E- 3%

2. Urine Routine & Microscopic test - NAD 2. Urine Routine & Microscopic test - NAD

3. PS FOR MP- NEGATIVE 3. PS FOR MP- NEGATIVE

4. X- Ray Chest – NAD4. X- Ray Chest – NAD

5. Blood Widal -VE5. Blood Widal -VE

6.Blood Glucose R-98 mg % 6.Blood Glucose R-98 mg %

7. S. Bilirubin 6.00 mg % 7. S. Bilirubin 6.00 mg % SGOT -70SGOT -70 SGPT -60SGPT -60 Hbs Ag- NEGATIVE Hbs Ag- NEGATIVE

8. Blood Urea 30 mg %8. Blood Urea 30 mg % S. Creatinine 1.4 mg %S. Creatinine 1.4 mg %

9. Widal – ve9. Widal – ve

10. Ultra Sonography shows Hepatosplenomegaly 10. Ultra Sonography shows Hepatosplenomegaly

11.Echo- NAD 11.Echo- NAD

X- RAY [ NAD ]X- RAY [ NAD ]

TREATMENT GIVENTREATMENT GIVEN Blood Transfusion II Blood Transfusion II Inj Arteethar 150 mg daily for three Inj Arteethar 150 mg daily for three

days days Inj Cefotaxim 1 gm bd Inj Cefotaxim 1 gm bd Inj metrogyl 500 mg 8 hourly Inj metrogyl 500 mg 8 hourly Symptomatic & Supportive Symptomatic & Supportive

Treatment Treatment He responded to treatment & He responded to treatment &

became afebrile on 3rd day became afebrile on 3rd day remained in the hospital for 10 days, remained in the hospital for 10 days, recovered and then discharged. recovered and then discharged.

On 4/10/2008 he again admitted to private Hospital with H/O On 4/10/2008 he again admitted to private Hospital with H/O Fever, Vomiting where he was again investigated Fever, Vomiting where he was again investigated

1. CBP Hb 8 gm %1. CBP Hb 8 gm % TWBC 9,300 TWBC 9,300 P- 70%P- 70% L- 20%L- 20% M- 3%M- 3% E- 3%E- 3% B- 4% B- 4%

2. 2. PS for MP -ve PS for MP -ve3. 3. Urine Routine Microscopic Test / NAD Urine Routine Microscopic Test / NAD 4. X- Chest – NAD 4. X- Chest – NAD 5. 5. S. Bilirubin 3.0 mg % S. Bilirubin 3.0 mg % SGOT & SGPTSGOT & SGPT

30 30 40 406. Reticulocyte count – 3%6. Reticulocyte count – 3%7. G6PD deff – Not Detected 7. G6PD deff – Not Detected 8.8. Sickling Test- -ve Sickling Test- -ve9.9. Coomb’s Test- -ve Coomb’s Test- -ve 10. Hb Electrophoresis (N) 10. Hb Electrophoresis (N) 11. USG-Hepatosplenomegaly11. USG-Hepatosplenomegaly12. ECG Within normal limit ( WNL)12. ECG Within normal limit ( WNL)

TREATMENT GIVENTREATMENT GIVEN

IV Ceftrixone 1 gm bd ..IV Ceftrixone 1 gm bd ..

IVIV GM 80 mg IV bd.. GM 80 mg IV bd..

IV Artesunate 120 gm IV Stat IV Artesunate 120 gm IV Stat than than 60 mg IV daily for 60 mg IV daily for Four DayFour Day

Remained in the Hospital for Remained in the Hospital for 5 5 days than dischargeddays than discharged

Again he came to my clinic on Again he came to my clinic on 16/12/08 with H/O Fever, vomiting 16/12/08 with H/O Fever, vomiting

O/E O/E Hb – 4.0 gm %Hb – 4.0 gm % TWBC -TWBC -28002800 P- 50%P- 50% L- 47%L- 47% M- 02M- 02 E- 01E- 01 PS- MP -VE PS- MP -VE S. Bilirubin – 3.6 mg % S. Bilirubin – 3.6 mg %

Bone Marrow ExaminationBone Marrow Examination

CELLULARITYCELLULARITY- Hypercellular - Hypercellular M: E RatioM: E Ratio:- 1:3 (reversal):- 1:3 (reversal)

ERYTHROPOISISERYTHROPOISIS: Show marked erythrorid : Show marked erythrorid hyperplasia with many precursors and few hyperplasia with many precursors and few macronormoblasts with feature of macronormoblasts with feature of dyserythropoisis few trophozoits and dyserythropoisis few trophozoits and schizoni of schizoni of P. Vivax seen. P. Vivax seen.

LYMPHOPOISISLYMPHOPOISIS :- Shows mild increase in :- Shows mild increase in lymphocytes..lymphocytes..

MEGAKARYOCYTESMEGAKARYOCYTES:- Normal in number but :- Normal in number but functioning functioning

IMPRESION IMPRESION :- Macronormoblastic erythrorid :- Macronormoblastic erythrorid hyperplasia secondary to P.Vivaxhyperplasia secondary to P.Vivax

Blood Transfusion II Blood Transfusion II

INJ – chloroquineINJ – chloroquine

TAB-TAB- PrimaquinePrimaquine

Symptomatic & supportiveSymptomatic & supportive

Drug Drug Indication Indication Adverse side Adverse side effects effects

Dose Dose

Chloroquine Chloroquine Phosphate Phosphate

Treatment of Treatment of all forms of all forms of malaria except malaria except for infection for infection due to due to resistant resistant strains of P. strains of P. falciparum falciparum

GI intolerance, GI intolerance, pruritus, pruritus, dizziness, dizziness, anorexia, anorexia, malsise rare- malsise rare- psychosis psychosis convulsions, convulsions, blood blood dyscrasiadyscrasia

Oral: 600 mg Oral: 600 mg stat then 300 stat then 300 mg base after mg base after 6 hours then 6 hours then 300 mg ODx2 300 mg ODx2 days. days. Injectable in a Injectable in a dose of 10 mg dose of 10 mg per kg by slow per kg by slow infusion over a infusion over a period of 8 hrs period of 8 hrs followed by 5 followed by 5 mg/kg every 8 mg/kg every 8 hrs until a hrs until a total dose of total dose of 25 mg/kg IM : 25 mg/kg IM : 3.5 mg 3.5 mg (base)/kg (base)/kg every 6 hours every 6 hours

Mefloquine Mefloquine hydrochloridhydrochloride e

Used for oral Used for oral prophylaxis prophylaxis and and treatment of treatment of chloroquin chloroquin resistant resistant and and multidrug multidrug resistant resistant P.falciparum P.falciparum malaria malaria

GI GI intolerance, intolerance, dizziness, dizziness, extrasystole, extrasystole, syncope syncope rarely rarely neuropsychineuropsychiatric atric symptoms symptoms

Adults: 15-Adults: 15-25 mg/kg25 mg/kg

Children: Children: 25mfg / kg 25mfg / kg

Quinine Quinine Suphate Suphate

Resistant Resistant falciparum falciparum malaria malaria

Cinchonism, Cinchonism, acute acute hemolytic hemolytic anemia, anemia, tinnitus, tinnitus, headache, GI headache, GI intolerance intolerance

Adults: 300-Adults: 300-600 mg thrice 600 mg thrice daily 5-7 days daily 5-7 days

Children: 25 Children: 25 mg/kg/day 8 mg/kg/day 8 hourly for 7 hourly for 7 days days

Artesonate Artesonate Servere malaria Servere malaria including cerebral including cerebral malaria. malaria.

Second line Second line treatment of treatment of chloroquin chloroquin resistant resistant falciparum falciparum malaria malaria

Transient and Transient and reversible reversible reticulocytopereticulocytopena, drug fever, na, drug fever, drug rash, drug rash, bradycardia, bradycardia, transient first transient first degree heart degree heart block block

Adults: Adults: Parenteral: Parenteral: 120 mg first 120 mg first day; 60mg day; 60mg next 4 days.next 4 days.

Oral: 100 mg Oral: 100 mg BD first day; BD first day; 50 mg BD x 4 50 mg BD x 4 days days

Children: 1.2 Children: 1.2 mg /kg x 5 mg /kg x 5 days days

Artemether Artemether (Latrither) (Latrither)

Server Server falciparum falciparum malaria cerebral malaria cerebral malaria malaria multidrug multidrug resistant resistant malaria malaria

RecticulocytopenRecticulocytopenia ia

Adults: 80 mg Adults: 80 mg (1 amp) IM BD (1 amp) IM BD on day 1. on day 1. followed by 80 followed by 80 mg IM OD X 4 mg IM OD X 4 days. days.

Children's: 1.6 Children's: 1.6 mg/kg BDx3 mg/kg BDx3 days days

Mepacrine Mepacrine Drug resistant Drug resistant falciparum falciparum malaria. malaria. Prophylaxis Prophylaxis chloroquin chloroquin resistant resistant falciparum falciparum malaria malaria

Dizziness GI Dizziness GI disturbances disturbances yellow yellow discoloration of discoloration of skin on skin on prolonged use prolonged use

For For prophylaxis: prophylaxis: 0.6-0.7 g/week 0.6-0.7 g/week

For treatment For treatment

0.9 gm on first 0.9 gm on first day day

0.6 gm on 0.6 gm on second and second and third day third day

0.3 gm on 0.3 gm on fourth, fifth, fourth, fifth, and sixth day and sixth day

THANK YOUTHANK YOU