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Malaria (Mosquitos (5 Species (P. Ovale, ovale tertian, relapsing., P.…
Malaria
Mosquitos
Breeding sites -stagnant wate, leaf axels
Life cycle VS Malaria life cycle
Infection in the blood
https://www.cdc.gov/malaria/about/biology/index.html
5 Species
P. Ovale, ovale tertian, relapsing.
P. Malariae, quartan.
P. Vivax, benign tertian, relapsing
P. Knowlesi – primate mainly
Plasmodium falciparum -Malignant tertian, most widespread.
Acquired immunity can be lost or altered by
Steroids
Splenectomy
Pregnancy
Immunosuppressive drugs
Prolonged residence in non-malarias areas
Transmission of Malaria
Blood transfusion
Syringe passage among IVDU
Female Anopheles spp
Organ transplantation like heart and kidney.
Congenital
Stained blood film
Plasmodium vivax
Plasmodium malariae
Plasmodium ovale
Plasmodium falciparum
Malaria in Pregnancy (Think mother and child)
Malaria in pregnancy partially immunes
Primi and secundi gravidae (pregnant for first or second time)
Abortion, still birth and premature labour
Low birth weight infants
Placental parasitaemia
Haemolytic anaemia -severe in the 2nd trimester in primipara
Increase in parasite rates and densities
Malaria in pregnancy non-immunes
Higher mortality 2-10 fold
Abortion, still birth, premature delivery
-Low birth weight for infants
Severe complications: hypoglycaemia, pulmonary oedema
Density of parasitaemia
Log median parasite count of 38 women during
first pregnancy
1775 /mm3
Log median parasite count of 175 non-pregnant women 185 /mm3
Log median parasite count of 38 women before conception 140 /mm3
Image slide 38
Pathogenesis in pregnancy
No deletiorious effects of quinine infusion on uterine or foetal function
The placenta selects for a parasite sub-population that binds chondroitin sulphate A.
This parasite sub-population preferentially sequesters and multiplies in the placenta.
Infected blood cells become trapped in the uterus because of their odd shape. That causes inflammation in the uterus,
Symptoms and Malaria tests
Symptoms
Fatigue, myalgia, arthralgia.
Headache, fever(continuous or remittent), lethargy, Sweats.
Muscular low backache.
Clinical features of uncomplicated Malaria
Headache
Flu-like symptoms
fever(continuous or remittent)
Myalgia, arthralgia, lower backache.
Children -> inactive, stop playing and eating.
Tinge of Jaundice. (explain why)
Clinical features of complicated Malaria
Cerebral Malaria
Seizures
Meningeal signs
Focal neurological signs
Decorticate rigidity – abnormal flexion
Decerebrate rigidity – abnormal extension
Anaemia
Sequestration
of parasitised erythrocytes
Of Iron
Dyserythropoiesis -defective development of red blood cells
Lysis
of parasitised erythrocytes
of non-parasitised erythrocytes
(immune mediated)
Erythrophagocytosis -Phagocytosis of RBC by macrophages.
Metabolic acidosis
Negative inotropism -weaken the force of muscular contractions.
Impaired level of consciousness, stupor, coma
Vomiting, abdominal pain
Hyperventilation =>Kussmaul breathing from kidney failure or diabetic ketoacidosis
K+ shift extracellularly
Treat with hydration, IV Fluid, and Oxygen.
Hypoglycaemia
Palpitations, tachycardia
Sweating, feeling of warmth
Shakiness, anxiety, nervousness
Pallor, coldness, clamminess
Dilated pupils (mydriasis)
Nausea, vomiting, abdominal discomfort, headache.
CNS symptoms:
Deteriorating consciousness
Generalised convulsions
Extensor posturing
Shock and coma
Renal failure
Monitoring:
Hourly urinary-output
Creatinine Levels (chronic renal failure, but not good indicator for acute renal failure)
Treatment
Hydration
Transfusion
Oliguria and later anuria
Incubation period of
7 days
.
Tests (see diagnosis)
Complications of Malaria
DIC -Pathogenesis: Platelet consumption
Renal failure
Jaundice (Effect on Liver and destruction of hepatocytes)
Thrombocytopenia -Pathogenesis: Sequestration and destruction of platelets
Haemoglobinuria (bursting of RBCs)
Hypoglycaemia (Protozoa consumes glucose for nutrients, and inhibits gluconeogenesis)
Pulmonary Oedema / Adult respiratory distress syndrome. (symptoms)
Diagnosis, Management, Treatment
Diagnosis
Clinical
History of travel
Great mimics
High index of suspicion
Misdiagnosis
Influenza
Meningitis
Viral hepatitis
Glandular fever
Parasitological
Immunological
Detect plasmodial LDH (Optimal)
Detect aldolase (ICT)
histidine-rich protein-2(ParaScreen)
Some detect certain types while other are pan specific
Molecular
PCR
DNA hybridisation- DNA probes
Management
Frequent assessment of vital signs
Artificial homeostasis, H2O, O2, H+, glucose, Na, Mg2+, Ca2+, Creatinine, BP, temperature, red cells
Assess and treat: hydration, hypoglycaemia, hypoxia
Measure and monitor urine output e.g catheter
Daily thin film to measure parasite count
Consider central venous line, arterial line
Pyrexia > 39C remove patient’s clothing, tepid sponge, fan and antipyretic
Consider other infections, cultures, lumbar puncture
Treatment
P. falciparum non-severe malaria
Proguanil+ atovaquone (Malarone)
Artemether + lumefantrine PO (Co-artem) –safest drug
Quinine PO and doxycycline or clindamycin
Mefloquine (Lariam) –less toxic
Other non Severe Malaria
Sulfadoxine + Pyrimethamine (Fansidar)
LATER: Add Primiquine to prevent relapse for
P. ovale, and P. vivax
Chloroquine
Severe P. Falciparum Malaria
Either Doxycycline or clindamycin
Switch to ORAL when tolerated
Artesunate IV
Cmax 1 h (oral), 5min(IV), 4-9 hours (IM)
metabolised in liver
Most rapid action - 95% clearance within 24 hours - all stages
half life 9 hours- (oral)
20-45 min (IV)
or IV Quinine
Side Effects
Buzzing in ears (tinnitus)
Dizziness
Nausea, anorexia
Blurred vision
Optic atrophy is rare
Hypoglycaemia
Cinchonism on day 2 or 3
ACT (combined therapy) Protects the slow acting drug
Delays development of resistance
Interventions
Mosquito control - adults
Screens
Bed nets
Room sprays
Impregnated tablets for electrical sockets
Repellents
Aerosols, mists and fogs
Ultra-low-volume techniques
Residual house-spraying, toxicity, resistance
Genetic control
larvae
Larvivorous fish
Larval control using pathogens and parasites
Physical control, filling in, drainage, container removal, covering water pots
Environmental manipulation
Chemical control, oils(larvae can’t breath), Paris Green, insecticides(must be biodegradable)
Integrated control
Treatment
Sulfadoxine-pyrimethamine -2nd trimester once and again in 3rd trimester
Given with tetanus toxoid
Malaria mixed infection
Epidemiology
Drug Resistance
