Malaria diagnostics, clinical presentation and treatment · •Artesunate: Post treatment...
Transcript of Malaria diagnostics, clinical presentation and treatment · •Artesunate: Post treatment...
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Malaria diagnostics, clinical
presentation and treatment
Kristine Mørch, MD, PhD
National centre for tropical infectious diseases
Haukeland university hospital
Bergen, Norway
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Malaria epidemiology
• Globally (WHO report 2014):
– 200 million cases
– 600 000 deaths
• Europe (ECDC report 2014):
– 5 161 cases
– 1/100 000/year
– Imported cases 99%
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Malaria Lithuania and Norway
0
20
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60
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120
140
2010 2012 2014
Lithuania
Norway
ECDC report 2014. MSIS Norway.
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Malaria life cycle
Anopheles
Sporozoites Liver schizont
Merozoite invade red cellParasites multiply in red cellsGametocytes multiply in mosquito
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Five species infect humans
Potentially severe malaria:
• P. falciparum
• P knowlesi
• (P. vivax)
Benign malaria:
• P. vivax (usually)
• P. ovale curtisi and wallikeri
• P. malariae
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Uncomplicated malaria – clinical
presentation
• Unspecific fever
• Headache, myalgia, nausea, vomiting,
diarrhoea
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Severe malaria clinical presentation
• Coma (cerebral malaria)
• Severe anaemia
• Kidney failure
• Acidosis
• Pulmonary oedema
• Hypoglycaemia
• Spontaneous bleeding
• Shock
• Haemoglobinuria
• Hyperparasitaemia (>2-4%)
Sequestration
7
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Diagnostics
• Giemsa stained blood
slides
• Rapid diagnostic tests
• PCR
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P. falciparum
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P. vivax
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Rapid diagnostic tests
• Detects
– Histidine rich protein-2
(P.falciparum specific)
– Plasmodium specific
aldolase (pan-malaria)
– Plasmodium associated
LDH (pan-malaria)
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WHO quality assurance reports
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PCR
• Detects parasite DNA
• Most sensitive method
• Not available in routine diagnostics
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PCR versus microscopy
Bergen – Norway
Ref: Haanshus, Mohn, Mørch et al. Malaria journal 2013.
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PCR versus microscopy
globally
• Meta analysis:
– 70 paired microscopy and PCR estimates from
endemic areas (Africa, Asia, Americas)
• Microscopy detected 50.8% of malaria cases
detected by PCR
Okell et al. JID 2009
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Artesunate compared to quinine
-efficacy
• Artesunate reduces mortality in endemic
areas:
– Relative risk 0.61 in adults
– Relative risk 0.75 in children
-Sinclair et al, Artesunate versus quinine for treating severe malaria. Cochrane Syst Rev 2011. -Dondorp, et al. AQUAMAT: Lancet, 2010.
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Treatment
• Severe
– Artesunate i.v.
– Quinine i.v.
– Change from i.v. to a full course of
oral drug when condition allows
• Uncomplicated P. falciparum
– Artemether-lumefantrine
– Atovaquone-proguanil
– Mefloquine
• P. vivax , P. ovale
– Chloroquine + primaquine
• P. malariae
– Chloroquine
Ref: WHO guidelines for the treatment of malaria 2010.
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• Mørch, Myrvang: Treatment of malaria in Norway. Tidsskr nor legeforen 2012.
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Side effects
• Artesunate: Post treatment heamolysis
– May require repeated blood transfusions
– Hgb should be monitored 2-4 weeks after
treatment
• Quinine: Arrythmia, hypoglycaemia,
cinchonism
– Infusion slow (2-4 hours)
– Cardiac monitoring during infusion
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Preparedness for severe malaria in
a non-endemic country
• Among all hospitals in Norway
– 40% (19/48) not artesunate or quinine available
– 6% no diagnostic methods available
• In Lithuania?
Ref: Heggheim, Blomberg, Mørch: Preparedness for severe malaria. Tidsskr Nor Legeforen. 2015.
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Malaria patient
• Previously healthy doctor
• Did not turn up at work as usual
• Colleges alarmed the police who found him in his home; confused
• Admitted to department of neurology withtentative diagnosis cerebral stroke
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Findings
• Dysphasia
• Awake but confused
• RF 40, puls 120, temperature 39
• Sent for MRI
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The nurse received information saving
the patient
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Test results
• Malaria rapid test: P. falciparum positiv
• Lactate: 10
• Platelets: 11
• Creatinine: 120
• Bilirubin: 121
• LD: 522
• INR 1.4, APTT 46, D-dimer > 20 (DIC)
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Blood smear
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Blood smear two hours later
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Treatment
• Artesunate
• Exchange transfusion
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Thank you for your attention
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Klausimai?