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TM: Clinical Malaria (ii) (Adults vs children (cough more in child,…
TM: Clinical Malaria (ii)
Adults vs children
cough more in child
convulsions common in both, esp child
children have shorter symptom hx
children recover quicker from coma
children have more neurological sequelae (10% vs <5%)
jaundice common in adults, rare in children
hypoglycaemia common in children, rare in adults
10% of adults get pul oedema+DIC, both rare in children
renal failure common in adults, rare in children
in non-immune pregnant women
2-10 increase in mortality
abortion
still birth
premature delivery
low birth weight
in partially immune pregnant women
abortion
stillbirth
premature delivery
placental parasitaemia (schizonts favour Rs in placenta + cord)
increase in parasite rates + densities
severe haemolytic anaemia (esp 1st/2nd pregnancy) in 2nd trimester
in HIV+ve pregnant women
increased prevalence + density of paracitaemia
increased placental + cord blood parasitaemia
Acquired P falciparum immunity
takes up to 1000 infections
can be lost/altered by pregnancy, steroids, prolonged residence in non-malarious area (continuous stimulation needed, VFR = risk factor), splenectomy, immunosuppressive drugs
Resistance
chloroquine resistance common
MDR strains exist
esp on Cambodia-Thailand border
esp with poor drug regulation (street drugs)
Transmission
airport (mosquitoes)
blood transfusion
syringes (IVDUs)
congenital (rare)
heart/kidney transplant (donors must be screened)
Dx
Clinical
high index of suspicion
hard to dx on signs/symptoms alone as is a mimicer
often misdxed as influenza, viral hep, meningitis
travel hx
Parasitological
Immunological
plasmodial LDH (best)
aldolase (ICT - rapd immunochromatographic assay)
Parascreen (HRP2)
some for P falciparum
some for P vivax
some pan-specific (both)
Molecular
PCR
DNA hybridisation (probes)
General management
frequent assessment of vitals
artificial homeostasis
H2O
O2
H+
glucose
Na+
Mg2+
Ca2+
creatinine (more for chronic renal failure, not acute as takes a few days to rise + catchup with GFR)
BP
temp
if >39 remove clothes, tepid sponge, fan, antipyretics
RBCs
Tx dehydration, hypoglycaemia, hypoxia
catheterise to monitor urine output
daily thin blood film to measure parasite count
consider venous/art line
consider other infections: cultures, lumbar puncture
Tx
antimalarials
artemisinin, arthemether, artesunate
most rapid - 95% clearance in 24 hrs @ any stage
Cmax @ 1 hr oral, 5 min IV, 4-9 hrs IM
metabolised in liver
T1/2 = 9 hrs oral, 20-45 min IV
Quinine
doesn't harm uterine/foetal function
associated with adverse effects: cinchonism/quinism on day 2/3
tinnitus
dizziness
nausea
anorexia
blurred vision
also hypoglycaemia + rarely optic atrophy (neuronal death)
Artemisinin-based combo Tx (ACT)
protects slow acting drug
delays resistance
severe P falciparum
IV artesunate or quinine AND doxycycline (lots of SEs - GI upset, sunburn, thrush) or clindamycin
switch to oral when tolerated
non-severe P Falciparum
artemether + lumefantrine PO (co-artem)
Mefloquine
good for resistance + prophylaxis
aka Lariam
not as toxic
weird dreams
other non-severe
chloroquine
sulfadoxine+pyrimethamine (fansidar)
or same as P falciparum
primaquine
destroys hyponozoites - prevents P vivax/ovale relapse
don't give in G6PD deficiency - causes severe haemolytic anaemia
cultural difference in preferred admin route (e.g. rectal suppositories)
while pregnant
sulfadoxine-pyrimethamine once in 2nd trimester, repeated in 3rd
given with tetanus toxoid
in endemic areas pre-emptively tx all pregnant women