Malaria - Update

Dr.Girish Vaswani (D.N.B. med)

Consulting Physician
Bhatia hospital
Motiben Dalvi
Kothari Hospital
 Plasmodium species which
infect humans
Plasmodium vivax ( B. tertian)
Plasmodium ovale ( B. tertian)
Plasmodium falciparum ( M.tertian)
Plasmodium malariae (quartian)
Malaria Life Sporogony
Cycle Oocyst

Life Cycle Sporozoites

Mosquito Salivary
Zygote Gland

Hypnozoites
Exo- (for P. vivax
and P. ovale)
erythrocytic
(hepatic) cycle
Gametocytes

Erythrocytic
Cycle

Schizogony
 Malaria Transmission Cycle
Exo-erythrocytic (hepatic) Cycle:
Sporozoires injected Sporozoites infect liver cells and
into human host during develop into schizonts, which release
blood meal merozoites into the blood

Parasites
mature in
mosquito
midgut and Dormant liver stages
MOSQUITO HUMAN
migrate to (hypnozoites) of P.
salivary vivax and P. ovale
glands

Erythrocytic Cycle:
Merozoites infect red
blood cells to form
Some merozoites schizonts
Parasite undergoes
sexual reproduction in differentiate into male or
the mosquito female gametocyctes
 Components of the Malaria Life Cycle
Sporogonic cycle

Infective Period

Mosquito bites
uninfected
person Mosquito Vector

Parasites visible Human Host

Mosquito bites
gametocytemic
Prepatent Period Symptom onset
person
Recovery

Incubation Period
Clinical Illness
 Clinical presentation

• Early symptoms
– Headache
– Malaise
– Fatigue
– Nausea
– Muscular pains
– Slight diarrhea
– Slight fever, usually not intermittent
• Could mistake for influenza or gastrointestinal
infection
 Clinical presentation

• Acute febrile illness, may have periodic febrile

paroxysms every 48 – 72 hours with
• Afebrile asymptomatic intervals
• Tendency to recrudesce or relapse over months to
years
• Anemia, thrombocytopenia, jaundice,
hepatosplenomegaly, respiratory distress syndrome,
renal dysfunction, hypoglycemia, mental status
changes, tropical splenomegaly syndrome
 Malarial Paroxysm

• Can get prodrome 2-3 days before

– Malaise, fever,fatigue, muscle pains, nausea, anorexia
– Can mistake for influenza or gastrointestinal infection
– Slight fever may worsen just prior to paroxysm
• Paroxysm
– Cold stage - rigors
– Hot stage – Max temp can reach 40-41o C,
splenomegaly easily palpable
– Sweating stage
– Lasts 8-12 hours, start between midnight and midday
 Malarial Paroxysm

• Periodicity
– Days 1 and 3 for P.v., P.o., (and P.f.) - tertian
– Usually persistent fever or daily paroxyms for
P.f.
– Days 1 and 4 for P.m. - quartian
 Differential diagnosis
At the onset of the disease it may be very difficult to
differentiate malaria from viral fevers.
Jaundice and fever is also seen in viral hepatitis and
other forms of hepatitis, cholecystitis and hepatic
abscess.
Dengue, Leptospirosis and hemolytic anemia have
the common triad of pallor, icterus and
splenomegaly.
P. Falciparum-cerebral malaria:A
symmetric encephalopathy
Whenever you see a patient who complains of
headache, vomiting, diplopia, and is disoriented,
confused or behaving abnormally then always
think MALARIA. The relatives may say that he is
always sleepy and had a few convulsions.
On examination, varying levels of consciousness
may be noted with divergent or convergent eyes,
release of primitive reflexes, hyper/hyporeflexia,
hyper/hypotonia, extensor/flexor plantars and
absent abdominals-cremasterics.
Signs of meningeal irritation may also be elicited.
 Cerebral Malaria-D/D
Always rule out other causes of altered
sensorium like encephalitis, menigitis and
cerebral bleeds and infarcts.
Check for metabolic parameters and renal and
hepatic failure as other diagnosis or as
contributing to reduced alertness or
convulsions
 As the disease progresses
The patient becomes more drowsy and breathless
suggesting ALI and ARDS.The O2 concentration
starts to drop and respiratory alkalosis sets in.
Eventually he may be started on mechanical
ventillation.
The kidneys start to fail and urine output lessens
signifying acute renal failure.
Shock,hypoglycemia, lactic acidosis and DIC
complete the picture of MOSF.
 Chronic malaria - tropical
splenomegaly
• Anorexia, nausea, vomiting, weight loss
• Symptoms due to anemia – pancytopenia
• Abdominal pain
• Abdominal lump
• Splenic rupture
 Tropical splenomegaly
• Patient from endemic area
• Many attacks of malaria in childhood
• Moderate to massive hepatosplenomegaly
• Smear negative for parasites
• Malarial antibodies positive
• Parasites in bone marrow
• Hypersplenism
 Tropical splenomegaly – diff
diagnosis
• Kala-azar
• Portal hypertension – hepatic, extrahepatic
• Myeloproliferative diseases
• Lymphomas
• CLL
Chronic complications of malaria
Tropical splenomegaly with or without
hypersplenism is very common.
Immunological complications like nephrotic
syndrome and a predisposition to Burkitt’s
lymphoma have also been reported.
 Diagnosis - malaria
A high index of suspicion is required and a
history of visit to a malarious tract should always
be sought by direct questioning of the patient or
accompanying persons.A history of recent blood
transfusion may point to an iatrogenic mode of
spread of malaria.
Thick and Thin smears should always be examined
and indirect evidence of malaria by demonstrating
hemolytic jaundice should be performed.
 Other tests
Generally the complete blood counts and platelets
counts are of little benefit in the diagnosis but aid
in assessing the severity and complications of the
ongoing infection.

PfHRP2 dipstick or card test: monoclonal ab

captures the parasite antigens. Only for falciparum
malaria.
LDH dipstick or card test
Drugs used to treat Malaria-First
group
• CHQ, Amiodaquine
• Quinine, Quinidine
• Mefloquine, Halofantrine
• Lumefantrine
 First group-adverse reactions
GI disturbances-nausea, vomiting, diarrhoea and
erosive or hemorrhagic gastritis with abdominal
pain and hematemisis at times.
Cardiovascular instability- Prolonged QTc
ventricular tachyarrythmia and hypotension
CNS-disorientation, abn behaviour, seizure
Metabolic- hypoglycemia
ALWAYS CHECK – K, MG, SUGAR before
starting
 Drugs used to treat malaria
• Doxy, Tetra – pregnancy, children, hepatic
• Sulfadoxine-Pyrimethamine – sulfa allergy,
renal failure
• Artemisin derivatives - safe
 Drugs used to treat Malaria-
others
• Clindamycin
• Azithromycin
• Proguanil
• Dapsone
• Primaquine
 How to select antimalarials
Type of malaria – vivax or falciparum?
Sensitive or resistant
Associated renal or liver damage
Associated metabolic-electrolyte imbalances
Pregnancy, weight
Drug reactions
Oral therapy possible?
 Intravenous anti-malarial
therapy- Indications
Presence of vomiting
Inability to start oral therapy may also be due
to altered mental alertness and seizures.
Patients who are intubated and on
ventillators.
Those who are critically ill.
 Intra-venous therapy
Chloroquine: intravenous 10 mg/kg max
600mg over 6-8 hrs followed by 15mg/kg
max 900mg over next 24 hrs as slow
infusion.
Quinine : intravenous 20mg/kg over 4 hrs;
then 10mg/kg(max 600mg)three times a
day.
 Intra-venous therapy-severe
f.malaria
Artesunate 2.4mg/kg stat; followed by 2.4mg/kg at
12 hrs, 24hrs and then daily. OR
Artemether 3.2mg/kg stat im; then 1.6mg/kg od im.
PLUS
Add quinine 20mg salt/kg over 4 hrs; followed by
10mg/kg over 2-8 hrs slow infusion thrice a day.
PLUS
Doxy 100mg bd / tetra 250mg (4mg/kg) qds
 Oral therapy-CHQ sensitive
malaria
Chloroquine 10mgbase/kg stat followed by
5mg/kg at 12, 24 and 36 hrs.
OR
Chloroquine 10mg/kg stat; then 10mg/kg at
24hrs and 5mg/kg at 48 hrs.
OR
Amodiaquine 10mg base/kg od x 3 days
 Oral therapy-sensitive f.malaria
Sulfadoxine-pyrimethamine 25mg/kg (max
1500mg of sulfadoxine) single dose
PLUS
Artesunate 4mg/kg od x 3 days
OR
Amodiaquine/CHQ plus artesunate
 Multidrug resistant malaria
Mefloquine 8mg base/kg orally od for 3 days,
or 15mg/kg and then 10mg/kg next day
PLUS
Artemether-lumefantrine (1.5/9mg/kg bid) or
artesunate 4mg/kg od for 3 days
 Multidrug resistant malaria- 2 nd

line
Doxy 100mg bd (3mg/kg x 7 days)
Artesunate 2mg/kg od or quinine 10mg/kg tds
PLUS
1 drug of the following:
Tetra 250mg qds (4mg/kg qid x 7 days)
Clindamycin 10mg/kg bd x 7 days or
atovoquone-proguanil 20/8 mg/kg od x 3
days
 Other supportive therapy
• Maintain acid-base balance
• Maintain blood sugar
• Add folvite for hemolysis
• Blood transfusions
• Exchange transfusion
 DISEASES SPREAD BY
MOSQUITOS
• MALARIA
• DENGUE FEVER
• YELLOW FEVER
• VIRAL ENCEPHALITIS
• VIRAL HEMORRHAGIC FEVERS
Malaria
 Malaria (cont’d)
• Avoid mosquitoes by taking protective measures.

• Use protective clothing: long sleeved shirts/pants.

• Use DEET repellant.

• Use bed netting if rural or if locked windows not available.

• Prophylactic medications when indicated are widely used based

on CDC recommendations for intended destinations.
 chemoprophylaxis
• Chloroquine 5mg base/kg (max 300 mg) once a
week. Begin 1-2 weeks before travel, during stay
and continue till 4 weeks after returning from
malarious area.
• Mefloquine 5mg salt/kg (max 250 mg) once a
week. Regime same as above.
• Atovoquone/proguanil (250/100mg) 1 tab for
travel to resistant malarious area beginning 1-2
days before travel and taken daily during stay and
ctd till 1 week after return from malarious area.
 Travel in Chloroquine Resistant areas
Atovaquone/proguanil (Malarone)

• 250 mg atovaquone and 100 mg proguanil hydrochloride.

• Begin 1-2 days before travel and continue daily for 7 days
after leaving the area..
• Daily, at the same time each day .
• Contraindicated in persons with severe renal impairment
• Contraindicated in children <5 kg, pregnant women, and
women breastfeeding.
• Side effects- abdominal pain, nausea, vomiting, and
headache
 Congenital malaria
• Transplacental infection
– Can be all 4 species
– Commonly P.v. and P.f. in endemic areas
– P.m. infections in nonendemic areas due to long persistence of species
• Neonate can be diagnosed with parasitemia within 7 days of
birth or longer if no other risk factors for malaria (mosquito
exposure, blood transfusion)
• Fever, irritability, feeding problems, anemia,
hepatosplenomegaly, and jaundice
• Be mindful of this problem even if mother has not been in
malarious area for years before delivery