MalariaMalaria By Dr. Osman Sadig By Dr. Osman Sadig

MalariaMalaria:: - - is a mis a major health problemajor health problem in developing in developing

tropical countries tropical countries::

11 - -Annual incidence of 300– 500 x 1000 000Annual incidence of 300– 500 x 1000 000

22 - -1%1% mortalitymortality, mainly in , mainly in under 5 yearsunder 5 years,,

pregnant ladies & non immunepregnant ladies & non immune

33 - -80%80% of cases & 90% of deaths in AFRICAof cases & 90% of deaths in AFRICA..

- -In SudanIn Sudan -: -:

11 - -250250 / /1010 000000 population/ year (7.5 millionpopulation/ year (7.5 million//

yearyear

22 - -3535 000000 deaths every yeardeaths every year

33 - -2020——40%40% of health institute attendanceof health institute attendance 44 - -2020——30%30% of total hospital admissionsof total hospital admissions

55 - -1515——20%20% of total deathsof total deaths 66 - -22%22% loss of working hoursloss of working hours

OrganismOrganism-:-: - - Plasmodium falciparumPlasmodium falciparum ( 95% in Sudan) ( 95% in Sudan)

- - P. vivaxP. vivax - - P. ovaleP. ovale

- - P. malariaeP. malariae ** ** P. falcip is endemic in the tropicsP. falcip is endemic in the tropics, has , has nono

hypnozoiteshypnozoites to sustain transmission which to sustain transmission which depends on the presence of vector all za depends on the presence of vector all za

yearyear . .

** ** P.f invades RBC of all ages, multipleP.f invades RBC of all ages, multiple

RBC infection is common & mature trophozRBC infection is common & mature trophoz

are absent in the peripheralare absent in the peripheral

bloodblood..

** ** P.fP.f is the only sp. of malaria associated with is the only sp. of malaria associated with

life threatening complicationslife threatening complications & is often & is often

drug resistantdrug resistant

** ** P.v. & P.o.P.v. & P.o. are endemic in the temperate are endemic in the temperate

zones, invade reticulocytes & cause zones, invade reticulocytes & cause relapsingrelapsing

malariamalaria..

** ** P.m.P.m. produces chronic low parasitaemia produces chronic low parasitaemia . .

** ** 55——7%7% of infections are multiple with moreof infections are multiple with more

than one spthan one sp..

** ** Light microscopyLight microscopy of stained BF is used to of stained BF is used to

diagnose malaria & identify the spsdiagnose malaria & identify the sps..

TransmissionTransmission 11 - -Female anopheles mosquitoFemale anopheles mosquito (A. gambiensis (A. gambiensis

and A. arabiensis). Transmission depends and A. arabiensis). Transmission depends onon

the presence of gametocytes in the peri the presence of gametocytes in the peri bloodblood

22 - -BT & sharing needlesBT & sharing needles. No relapse with this. No relapse with this

mode of transmissionmode of transmission

33 - -TransplacentalTransplacental Congenital malaria Congenital malaria

EpidemiologyEpidemiology Transmission of malariaTransmission of malaria depends on the depends on the

presence of presence of -: -:

11 - -Infected reservoirInfected reservoir

22 - -Susceptible human beingSusceptible human being

33 - -Competent vectorCompetent vector

44 - -Multiple opportunities for contactMultiple opportunities for contact betweenbetween

the vector & human hostthe vector & human host..

Endemicity of malariaEndemicity of malaria - -Endemicity is the amount & severity of Endemicity is the amount & severity of

malariamalaria in an area or communityin an area or community..

- - Prevalence of malariaPrevalence of malaria= to estimate the = to estimate the prevalpreval

of malaria a large No of people, sp infants of malaria a large No of people, sp infants andand

children must be examined bychildren must be examined by:: 11 - -Spleen rateSpleen rate: this is the proportion of: this is the proportion of

children (2-10 years) in a communitychildren (2-10 years) in a community who have enlarged spleenwho have enlarged spleen::

- - hypoendemic= spleen rate of 0-10%hypoendemic= spleen rate of 0-10% - - mesoendemic= spleen rate of 11-50%mesoendemic= spleen rate of 11-50%

- - hyperendemic= spleen rate of over 50%hyperendemic= spleen rate of over 50% - - holoendemic= spleen rate over 75%holoendemic= spleen rate over 75%

22 - -Parasite rateParasite rate= it is the proportion of = it is the proportion of persons in a given community persons in a given community who show parasites in the who show parasites in the peripheral bloodperipheral blood..

ImmunityImmunity 11 - -Natural resistanceNatural resistance depends on cellular factors depends on cellular factors

that prevent penetration & development ofthat prevent penetration & development of parasites in the RBCs (G6PD def & HbC) andparasites in the RBCs (G6PD def & HbC) and

the susceptibility of parasitized cells tothe susceptibility of parasitized cells to removal from circulation by lymphoid macropremoval from circulation by lymphoid macrop

system (Hb AS, Hb F, Hb C), the latersystem (Hb AS, Hb F, Hb C), the later protects against severe complicated malariaprotects against severe complicated malaria..

P.v can not invade RBCs with duffy bloodP.v can not invade RBCs with duffy blood groupgroup

22 - -Acquired resistanceAcquired resistance is either passive is either passive transplacental which persists for 6/12 ORtransplacental which persists for 6/12 OR

active resistance which is sp & stage specificactive resistance which is sp & stage specific..

Humoral immunity deals with extracellularHumoral immunity deals with extracellular

parasites & cellular immunity deals with intracellparasites & cellular immunity deals with intracell

parasites. The Spleen traps & removes parasites. The Spleen traps & removes parasitized cellsparasitized cells..

PathogenesisPathogenesis - - Invasion of RBCs by malaria parasites is commInvasion of RBCs by malaria parasites is comm

to all sp. causing to all sp. causing hemolysis, fever & splenomehemolysis, fever & splenome

- - P.f is the only sp. that causes microvascular P.f is the only sp. that causes microvascular dis. dis. With maturation of P.f the parasitized With maturation of P.f the parasitized RBCs become spherical and knobs appear on RBCs become spherical and knobs appear on the surface facilitating cytoadherance tothe surface facilitating cytoadherance to

endoth cells of capillaries & post capillary endoth cells of capillaries & post capillary venules of vital organs. Cytokines venules of vital organs. Cytokines (TNF alpha) increases cytoadherance (TNF alpha) increases cytoadherance and microvascular obstruction, tissue and microvascular obstruction, tissue anoxia and wide spread organ failureanoxia and wide spread organ failure..

11-- FeverFever is due to rupture of the schizonts is due to rupture of the schizonts releasing toxic substances stimulatingreleasing toxic substances stimulating

macrophages to release endogenous macrophages to release endogenous pyrogenpyrogen

raising temp. via the hypothalamusraising temp. via the hypothalamus 22-- AnaemiaAnaemia: rapidly developing anaemia is a: rapidly developing anaemia is a feature of P.f in children < 5y & pregn ladiesfeature of P.f in children < 5y & pregn ladies

- - hemolysis of parasitized & unparasitizedhemolysis of parasitized & unparasitized RBCsRBCs

- - dyserythropoiesis - TNF alphadyserythropoiesis - TNF alpha.. - - haemodilution from sequestration of RBCshaemodilution from sequestration of RBCs

in the spleenin the spleen - - depletion of folate storesdepletion of folate stores

33 - -HypoglycemiaHypoglycemia:- related to the degree of:- related to the degree of

parasitaemiaparasitaemia

- - depletion of glycogen stores from low intakedepletion of glycogen stores from low intake

- - Increased Glucose consumption by the largeIncreased Glucose consumption by the large

numbers of parasitesnumbers of parasites..

- - Hypoglycemic effect of TNFHypoglycemic effect of TNF

- - Quinine therapy & release of insulinQuinine therapy & release of insulin

- - Suppression of gluconeogenesisSuppression of gluconeogenesis

44 - -Black water feverBlack water fever wz severe intravas wz severe intravas hemolyshemolys

causing anaemia, Hb uria & renal failurecausing anaemia, Hb uria & renal failure

55 - -Immune Immune thrombocytopenia & coagulopathythrombocytopenia & coagulopathy

66-- LiverLiver:- congested & enlarged with :- congested & enlarged with centrilobular necrosis in severe casescentrilobular necrosis in severe cases

77 - -JaundiceJaundice: either hemolytic or hepato cellular: either hemolytic or hepato cellular..

Hepato renal syndrome can occurHepato renal syndrome can occur..

88 - -SpleenSpleen: there is R/E hyperplasia with : there is R/E hyperplasia with congestion, hage & thrombosis. Spleen is congestion, hage & thrombosis. Spleen is tender & may rupture. Hypersplenismtender & may rupture. Hypersplenism..

99 - -KidneysKidneys: Ischemic pre renal failure may occur: Ischemic pre renal failure may occur

as well as immune complex nephritisas well as immune complex nephritis

1010 - -CNSCNS: congested meningeal & cerebral capill: congested meningeal & cerebral capill

with parasitized RBCs with ring hage & mild with parasitized RBCs with ring hage & mild reversible peri vascular inflammation reversible peri vascular inflammation . .

1111-- LungsLungs: pulm edema: pulm edema

1212-- GITGIT: micro vascular dis causes mucosal: micro vascular dis causes mucosal

edema, hage & ulceration causing D & edema, hage & ulceration causing D & VV

1313-- AdrenalsAdrenals: congestion & hage: congestion & hage

1414-- PlacentaPlacenta: may be heavily parasitized : may be heavily parasitized sp. Insp. In

PG & may cause abortion & low birth PG & may cause abortion & low birth WtWt..

Uncomplicated malariaUncomplicated malaria Case definitionCase definition::

11 - -Suspected malariaSuspected malaria: Malaria is suspected when: Malaria is suspected when

a pat presents with fever (or history of fevera pat presents with fever (or history of fever

in za last 24 hours) and other S & S suggestivein za last 24 hours) and other S & S suggestive

of malaria after exclusion of other commonof malaria after exclusion of other common

causes of fever in the areacauses of fever in the area..

22 - -Confirmed malariaConfirmed malaria: Malaria is confirmed by: Malaria is confirmed by

demonstration of asexual forms of za parasitedemonstration of asexual forms of za parasite

in za thick or thin peri BF or by rapid diagnostin za thick or thin peri BF or by rapid diagnost

test in the presence of fevertest in the presence of fever

* * When malaria is suspected & there is noWhen malaria is suspected & there is no facilities for lab. diagnosis., assume that the facilities for lab. diagnosis., assume that the

pat has malaria when there is no other pat has malaria when there is no other obvious cause for za feverobvious cause for za fever..

* * Incubation periodIncubation period is 9—14 days in P.f is 9—14 days in P.f * * Periodic feverPeriodic fever is the hallmark of malaria and is the hallmark of malaria and

coincides with rupture of RBCs & release ofcoincides with rupture of RBCs & release of new merozoitesnew merozoites..

- -Tertian wz P.v & P.oTertian wz P.v & P.o - - Quartan wz P.mQuartan wz P.m

- - Contin. wz irregular intermittent spikesContin. wz irregular intermittent spikes wz P.f, sometimes quotidian or sub wz P.f, sometimes quotidian or sub

tertiantertian

* * ParoxysmsParoxysms:: - -Cold stageCold stage —15 min to hours —15 min to hours

- -Hot stageHot stage –2—6 hours –2—6 hours - -Sweating stageSweating stage —2—4 hours —2—4 hours

* * Anaemia & splenomegalyAnaemia & splenomegaly are other signs are other signs * * Herpes labialisHerpes labialis is common is common

* * Natural history of falciparum malariaNatural history of falciparum malaria varies varies from from rapidly fatal in the non immunerapidly fatal in the non immune to to no no

symptom in semi immunesymptom in semi immune even with significa even with significa parasitaemia. In non immune hyperparasitparasitaemia. In non immune hyperparasit

with double infection (>5%) may lead to fatalwith double infection (>5%) may lead to fatal outcome in za absence of skilled outcome in za absence of skilled

managementmanagement..

Lab diagnosis of malariaLab diagnosis of malaria 11 - -Thick BF stained with GiemsaThick BF stained with Giemsa is is

examinedexamined microscopically formicroscopically for::

- -presence of infectionpresence of infection - - Stage of parasiteStage of parasite

- - parasite countparasite count + + 11——1010 parasites/ 100 fieldsparasites/ 100 fields

++ ++ 1111——100100 parasites/ 100 fieldsparasites/ 100 fields +++ +++ 11——1010 parasites/ one fieldparasites/ one field

++++ ++++ 1111——100100 parasites/ one fieldparasites/ one field

* * Thin BF is used where sp other than P.f Thin BF is used where sp other than P.f coexistcoexist

22 - -Rapid diagnostic testsRapid diagnostic tests e.g. ICT. This is not e.g. ICT. This is not

good in areas of high transmission wheregood in areas of high transmission where

asymptomatic parasitaemia & antigenaemiaasymptomatic parasitaemia & antigenaemia

is common. is common. High costHigh cost but can be used by but can be used by

unskilled personaleunskilled personale, used in , used in emergencyemergency and and epidemic situationsepidemic situations & where the cost of & where the cost of malaria TR is high to avoid unnecessary malaria TR is high to avoid unnecessary use of drugsuse of drugs..

Other investigations include: CBC, urine examOther investigations include: CBC, urine exam

BUN & E, blood sugar & serum bilirubinBUN & E, blood sugar & serum bilirubin..

Management of uncomplicated malariaManagement of uncomplicated malaria1-11-1stst line TR line TR:- Artsunate + sulfadoxine- pyremeth:- Artsunate + sulfadoxine- pyremeth

- - ArtsunateArtsunate (AS)= tabs of 50, 100 & 200 mg (AS)= tabs of 50, 100 & 200 mg

SESE= transient rise in transaminases & transien= transient rise in transaminases & transien

reduction in reticulocytesreduction in reticulocytes

- - Sulfadoxine- pyremethamineSulfadoxine- pyremethamine (SP)= fixed dose (SP)= fixed dose

schozonticidal combination against P.fschozonticidal combination against P.f

SP= 500 mg sulfadoxine + 25 mg pyremethSP= 500 mg sulfadoxine + 25 mg pyremeth

in tab & injection formsin tab & injection forms..

SESE= GIT, visual disturbance & cutaneous= GIT, visual disturbance & cutaneous

reactionsreactions

* *Dose regimensDose regimens-:-:

- - 11stst day= 4 mg/ kg BW AS + 25 mg/kg BW day= 4 mg/ kg BW AS + 25 mg/kg BW

sulfadoxine + 1.25 mg/kg BW pyremethsulfadoxine + 1.25 mg/kg BW pyremeth

- - 22ndnd day= 4 mg/ kg BW AS 24 h after 1 day= 4 mg/ kg BW AS 24 h after 1stst dose dose

- - 33rdrd day= 4 mg/ kg BW AS 24 h after 2 day= 4 mg/ kg BW AS 24 h after 2ndnd dose dose

* * TR failureTR failure is not always due to parasite resist is not always due to parasite resist??

If BF or RDT is +ve go toIf BF or RDT is +ve go to::

22 - -22ndnd line TR line TR: : ArtemetheArtemether (ARM) 20 mg- r (ARM) 20 mg- lumeflumef

antrine (LF) 120 mg fixed dose comb. wz highantrine (LF) 120 mg fixed dose comb. wz high

clinical & parasitological cure rate & rapid clinical & parasitological cure rate & rapid gametocyte clearancegametocyte clearance

SESE= GIT, dizziness, fatigue, palpitation, = GIT, dizziness, fatigue, palpitation, headache skin rash, arthralgia,& headache skin rash, arthralgia,& myalgia. No serious cardiotoxicitymyalgia. No serious cardiotoxicity

** ** Dose regimensDose regimens: 4 tabs 1: 4 tabs 1stst, repeated after 8h, repeated after 8h

then 4 tabs M & E 2then 4 tabs M & E 2ndnd & 3 & 3rdrd day, better taken day, better taken

with fatty meal or milkwith fatty meal or milk..

33 - -33rdrd line TR line TR: Quinine (Q) dihydroCL, Q CL or: Quinine (Q) dihydroCL, Q CL or

Q SO4 used if no response ARM/ LF (lab+ve)Q SO4 used if no response ARM/ LF (lab+ve)

** ** Dose regimensDose regimens: Oral= 10mg/kg 8 hrly x 7 D: Oral= 10mg/kg 8 hrly x 7 D

- - Injectable Q diluted IM or IV infusion 10mgInjectable Q diluted IM or IV infusion 10mg//

kg & shift to oral as soon as possiblekg & shift to oral as soon as possible

Severe malaria ( SM)Severe malaria ( SM) - -SM is defined as malaria due to P.f infectionSM is defined as malaria due to P.f infection

sufficiently serious to be an immediate threat sufficiently serious to be an immediate threat toto

life. It is life. It is med emergencymed emergency & require hospitalizati & require hospitalizati - -A pat is regarded as havingA pat is regarded as having severe malaria severe malaria ifif

he or she has one or more of the followinghe or she has one or more of the following:: 11 - -Impaired level of consciousness (cerebral Impaired level of consciousness (cerebral

malmal 22 - -Resp distress (acidotic breathing)Resp distress (acidotic breathing)

33 - -Repetitive convulsionsRepetitive convulsions 44--Circulatory collapseCirculatory collapse

55 - -Pulm edemaPulm edema 66 - -Abn bleeding (DIC)Abn bleeding (DIC)

77 - -JaundiceJaundice 88 - -Hb uriaHb uria

99 - -ProstrationProstration 1010 - -Severe anaemia (Hb < 5gm/dl)Severe anaemia (Hb < 5gm/dl) 1111 - -Hypoglycemia ( BS < 40mg/dl)Hypoglycemia ( BS < 40mg/dl)

1212 - -AcidosisAcidosis 1313 - -Hyperlactinaemia ( lactic acidosis)Hyperlactinaemia ( lactic acidosis) 1414 - -Hyperparasitaemia ( >5% RBCs wz Hyperparasitaemia ( >5% RBCs wz

ringring stagestage))

1515 - -Renal impairmentRenal impairment 1616 - -Electrolyte imbalance (hyponatraemia)Electrolyte imbalance (hyponatraemia) *** ***TSS is a chronic complication of malariaTSS is a chronic complication of malaria

Differential diagnosis of malariaDifferential diagnosis of malaria - - FeverFever: infections ( viral, bacterial, : infections ( viral, bacterial,

protozoal)protozoal)

- - RigorsRigors: UTI, septicemia, gall stones & : UTI, septicemia, gall stones & cholecycholecy

pneumonia, amoebic liver abspneumonia, amoebic liver abs

- - Cerebral malariaCerebral malaria: meningitis, stroke, : meningitis, stroke, encephalitencephalit

metabolic in comatosed patsmetabolic in comatosed pats,,

heat strokeheat stroke

- - Other causes of anaemia & splenomegalyOther causes of anaemia & splenomegaly

e.g typhoid, brucellosise.g typhoid, brucellosis

11 - -General management of SM(8+8+4)General management of SM(8+8+4)* * * *Immediate measuresImmediate measures::

11 - -Start resuscitation- ABCStart resuscitation- ABC

22 - -IV lineIV line

33 - -Thick BF for immediate parasite countThick BF for immediate parasite count

44 - -Assess degree of dehydration, fluid requiremAssess degree of dehydration, fluid requirem

and correct accordinglyand correct accordingly

55 - -Control fever if axillary temp 38.5 or aboveControl fever if axillary temp 38.5 or above

by tepid sponge & fanning, paracetamolby tepid sponge & fanning, paracetamol

15mg/kg 4—6 hourly15mg/kg 4—6 hourly

66 - -Control convulsion by diazepam. Correct Control convulsion by diazepam. Correct hypogly 7- Detect & TR hypoglycemia which hypogly 7- Detect & TR hypoglycemia which can recur specially in pregnant women can recur specially in pregnant women & children& children

Give 1 ml/kg of 50% dextrose IV diluted inGive 1 ml/kg of 50% dextrose IV diluted in

equal volume of NS over 3-5 min. followed byequal volume of NS over 3-5 min. followed by

10%10% dextrose infusiondextrose infusion

88 - -Start Q IV or ARM IM. Q IM or AS suppositStart Q IV or ARM IM. Q IM or AS supposit

can do the jobcan do the job..

** ** Look & deal with following complicationsLook & deal with following complications::

11 - -Shock, algid malaria: if SBP < 80mmHgShock, algid malaria: if SBP < 80mmHg

suspect septicemia & take blood samples forsuspect septicemia & take blood samples for

cultures. Give parentral broad spectrumcultures. Give parentral broad spectrum

antibiotics, saline infusion & O2antibiotics, saline infusion & O2

22 - -Consider the need for BT: transfuse if thereConsider the need for BT: transfuse if there

is cardiopulm symptoms, PCV <20% or Hb<5is cardiopulm symptoms, PCV <20% or Hb<5

33 - -Metabolic acidosis: exclude & TR hypoglycemMetabolic acidosis: exclude & TR hypoglycem

hypovolaemia & gm –ve septicemiahypovolaemia & gm –ve septicemia..

44 - -Spontaneous bleeding & coagulopathy: freshSpontaneous bleeding & coagulopathy: fresh

screened whole BT or clotting factors, Vit Kscreened whole BT or clotting factors, Vit K

10mg IV daily for adults10mg IV daily for adults

55 - -Acute renal failure: exclude dehydr, maintainAcute renal failure: exclude dehydr, maintain

strict fluid balance. Dialysis if indicatedstrict fluid balance. Dialysis if indicated

66 - -Black- water fever (malarial Hb uria): suitableBlack- water fever (malarial Hb uria): suitable

antimalarial & screened fresh BTantimalarial & screened fresh BT

77 - -Acute pulm edema: prevent by avoidingAcute pulm edema: prevent by avoiding

overload. IV frusemide & O2 overload. IV frusemide & O2 8- Exclude common infections that mimic 8- Exclude common infections that mimic malariamalaria

e.g. WBC, L/P & CXRe.g. WBC, L/P & CXR

** ** Monitor the patientMonitor the patient::

11 - -level of consciousness by Glasgow scale 6 hrly level of consciousness by Glasgow scale 6 hrly toto

assess the progress until the pat regainsassess the progress until the pat regains

full consciousnessfull consciousness

22 - -Fluid input/ output: detect dehydr & TR but Fluid input/ output: detect dehydr & TR but avoidavoid

overload e.g pulm edemaoverload e.g pulm edema

33 - -Monitor vital signs every 6 hrs to detectMonitor vital signs every 6 hrs to detect

compl of SMcompl of SM

44 - -level of parasitaemia: monitor parasite countlevel of parasitaemia: monitor parasite count

daily to monitor therapeutic effectdaily to monitor therapeutic effect

22-- Specific treatment of SMSpecific treatment of SM ** ** Pre referral TRPre referral TR: Q IM or AS suppositories: Q IM or AS suppositories

10mg/kg rectal caps. Then refer to hospital10mg/kg rectal caps. Then refer to hospital

** ** Hospital TRHospital TR::

11 - -Q IV infusion or IMQ IV infusion or IM if IV is not feasible & shift if IV is not feasible & shift to oral as soon as possible. Total of to oral as soon as possible. Total of 10mg/kg 8 hrly for 7 days10mg/kg 8 hrly for 7 days

22 - -Q for 3 days & shift to 1Q for 3 days & shift to 1stst line therapy line therapy if the if the

patient can take oral medication & can not patient can take oral medication & can not tolerate oral Q tolerate oral Q..

SESE= N, V & tinnitus. Over dose cause HA, dizzi= N, V & tinnitus. Over dose cause HA, dizzi,,

CNS dist & delerium, hypoglycemia, hypotnCNS dist & delerium, hypoglycemia, hypotn

33 - -ARM injectionsARM injections ( 40mg & 80mg/ml) as ( 40mg & 80mg/ml) as

monotherapy should only be used for SMmonotherapy should only be used for SM

- - 1.61.6 mg/kg initially, repeated after 12 hrsmg/kg initially, repeated after 12 hrs

and then daily for 6 days (total of 8 amp)and then daily for 6 days (total of 8 amp)

- - 1.61.6 mg/kg initially, repeated after 12 hrsmg/kg initially, repeated after 12 hrs

and then daily in za 2and then daily in za 2ndnd & 3 & 3rdrd day (4 amp) day (4 amp)

followed by the 1followed by the 1stst line TR if the pat can line TR if the pat can

take orallytake orally..

- - SESE of ARM are mild= HA, abd pain, of ARM are mild= HA, abd pain, vomitingvomiting

itching, non specific ST changes & 1itching, non specific ST changes & 1stst

degree A/V blockdegree A/V block..

Malaria in pregnancy (MIP)Malaria in pregnancy (MIP) 11--The manifestation of malaria in pregThe manifestation of malaria in preg, ,

speciallyspecially in the 2in the 2ndnd half, include half, include::

- -fever - anaemiafever - anaemia - - splenomegaly - acute pulm edemasplenomegaly - acute pulm edema

- - hypoglycemia - 2ndry infectionshypoglycemia - 2ndry infections 22 - -Management of MIPManagement of MIP: TR malaria & compl: TR malaria & compl , ,

manage labourmanage labour - - 11stst trimester trimester= oral Q is safe 10mg/kgx3x7= oral Q is safe 10mg/kgx3x7

- - 22ndnd & 3 & 3rdrd trimester trimester= oral Q for 7 days OR= oral Q for 7 days OR oral Q for 3 days followed by SP in full doseoral Q for 3 days followed by SP in full dose

OR use 1OR use 1stst line TR line TR

33 - -Management of SM during pregManagement of SM during preg::

- - Q 10mg/kg x3x7 days through out pregQ 10mg/kg x3x7 days through out preg

- - Start wz IV infusion or IM & shift to oral ORStart wz IV infusion or IM & shift to oral OR

- - Start wz Q IV or IM for at least for 3 days ORStart wz Q IV or IM for at least for 3 days OR

then shift to 1then shift to 1stst line TR in 2 line TR in 2ndnd & 3 & 3rdrd trim OR trim OR

- -ARM injections for 7 daysARM injections for 7 days

- - Management of pulm edema, hypoglycemiManagement of pulm edema, hypoglycemi

anaemia wz packed cell transfusion, renal Fanaemia wz packed cell transfusion, renal F

and septicaemic shock or algid malaria byand septicaemic shock or algid malaria by

33rdrd generation cephalosporin, monitoring of generation cephalosporin, monitoring of

vital signs & fluids if required (SBP< 90)vital signs & fluids if required (SBP< 90)

44 - -Intermittent preventive TR (IPT)Intermittent preventive TR (IPT)::

- - recommended only in high recommended only in high transmissiontransmission

areasareas

- - SP= 1SP= 1stst dose in za 1 dose in za 1stst ANC visit after ANC visit after quickening (16-20W) quickening (16-20W)

- - 22ndnd dose 4W later dose 4W later

TR of Vivax malariaTR of Vivax malaria - - malaria other than P.f constitute 5—15% inmalaria other than P.f constitute 5—15% in

Sudan, mainly in eastern borders. Death isSudan, mainly in eastern borders. Death is

rare & relapse expected wz P.v & Porare & relapse expected wz P.v & Po..

- - Still sensitive to CQ & susceptible to ARM/LFStill sensitive to CQ & susceptible to ARM/LF

- - Primaquine used following TR of asexual Primaquine used following TR of asexual formsforms

to clear exsoerythrocytic phase 15mg/d x14 to clear exsoerythrocytic phase 15mg/d x14 dd..

CI in preg, during lactation & children < CI in preg, during lactation & children < 1year1year

Malaria prophylaxis & preventionMalaria prophylaxis & prevention - - The following are at higher risk for malariaThe following are at higher risk for malaria::

11 - -travelers from malaria free areastravelers from malaria free areas 22 - -preg women, sp primigravidapreg women, sp primigravida

33 - -SS disSS dis 44 - -splenectomized individualssplenectomized individuals

55 - -children on steroids & immunosupp children on steroids & immunosupp drugsdrugs

66 - -expatriates & sudanese returning fromexpatriates & sudanese returning from non malarious areasnon malarious areas

- - MefloquineMefloquine 250mg weekly, starting one 250mg weekly, starting one weekweek

before entering the area & for 4W afterbefore entering the area & for 4W after leaving za arealeaving za area..

Mefloquine not recommended in children Mefloquine not recommended in children < 3/12< 3/12

- - atovaquine 250mg + proguanil 100mgatovaquine 250mg + proguanil 100mg beginbegin

one day before entering the area & for 7 one day before entering the area & for 7 daysdays

after leaving the area in those can not after leaving the area in those can not taketake

MefloquineMefloquine..

Tropical splenomegaly (TSS)Tropical splenomegaly (TSS) - - Results from Results from abn immunological responseabn immunological response to to

malariamalaria - - Occurs in Occurs in malaria endemic areasmalaria endemic areas in the in the

indigenous inhabitants. Parasites not presentindigenous inhabitants. Parasites not present - - There is There is high malarial Ab titre wz over- produchigh malarial Ab titre wz over- produc

of IgMof IgM & reduced C3 & reduced C3 - - Massive splenomegalyMassive splenomegaly >10cm which is firm >10cm which is firm

- - Hepatic sinusoidal dilatation, infilt wz lymphocyHepatic sinusoidal dilatation, infilt wz lymphocy and Kupffer cell hyperplasiaand Kupffer cell hyperplasia

- - PancytopeniPancytopenia with normocytic normochromica with normocytic normochromic anaemia & reticulocytosisanaemia & reticulocytosis

- - The condition is The condition is reversiblereversible - - Increased susceptibility to infectionIncreased susceptibility to infection & there is & there is

wasting in advanced caseswasting in advanced cases - - Criteria for diagn of TSSCriteria for diagn of TSS: exclusion of other: exclusion of other

causes of massive splenomegaly, immunity tocauses of massive splenomegaly, immunity to malaria, raised IgM, hepatic sinusoidalmalaria, raised IgM, hepatic sinusoidal lymphocytosis & IgM on immunofl & thelymphocytosis & IgM on immunofl & the

response to anti malarial prophylaxisresponse to anti malarial prophylaxis - - TR for symptomatic pats with anaemia & largeTR for symptomatic pats with anaemia & large

spleen-spleen----- Chemoprophylaxis Chemoprophylaxis + F acid + F acid SplenectomySplenectomy wz permanent malaria wz permanent malaria

chemoprophylaxis in those who fail to chemoprophylaxis in those who fail to respondrespond..