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PBL AA, Caused by - Coggle Diagram
PBL AA
Learning Outcome 5:
Treatment
Alternative drugs to
Chloroquinine Sulfate
COMPLICATED MALARIA: Artemisnin Group
for
falciparum malaria
RECOMMENDED DOSAGE
:
Artesunate 2.4 mg/kg (IV/IM) BD on day 1 followed by 2.4 mg/kg OD for 7 days
Artemether 3.2 mg/kg (IM) on day 1 followed by 1.6 mg/kg OD for 7 days
Arteether 3.2mg/kg (IM) on day 1 followed by 1.6 mg/kg OD for the next 4 days
-switch to 3 days oral meds of Artemisinin-based combination therapy if pts can take oral
Suggested IV treatment for rapid onset of action
MOA
Heme iron in parasite cleaves the endoperoxide bridge in the compound that generate the highly reactive free radicals
the highly reactive free radicals compound binds covalently to membrane proteins
damage of parasite membrane
Effective in treatment of
choloquine- resistance malaria
PRECAUTION:
Adverse Effect: Lower the neutrophil count and brief episodes of fever
Prophylaxis of visiting malarial country
Mefloquine 250mg once a week (should be also used long with Artesunate)
Doxycycline 100mg OD
Atovaquonene + proguanil OD
1-2 weeks before, during, 4 weeks min after returning from endemic area
Side Effect of Drugs
Choloquinine Sulfate
Headache
Nausea
Loss of Apetite
Diarrhea
Retinal damages
PRECAUTION:
Retinal damage
Patient has eye problem that could be
retinal damage and he has to undergo a regular ophthalmic examination before starting any dose.
Learning Outcome 2:
Sign and symptoms
After admission
Dehydrated
Had watery stools after returned to Angola
Dehydration and intestinal bleeding
Impaired thirst mechanism
Leading to hyponaterima
Seizure
Cerebral malaria
Parasite-filled blood cells block small blood vessels to the brain
Swelling brain
Permanent brain damage
Due to the red blood cells rupture
Altered mental
Predispose to depression
Predispose by malaria
Affecting immunity
Altering behaviour
Low sodium levels
Splenomegaly (Massive enlargement of spleen)
Filter and destroy Plasmodium-parasitized RBCs
Spleen rupture and splenomegaly
Lethargic
Destruction of red blood cell
Cause by malaria parasite
Severe anemia
Drowsy
Weak
Faint
Unable to carry enough oxygen
Muscles
Organs
Infect red blood cells
Due to the invasion of the parasite
Extensive changes in host of the cell
Loss of the normal discoid shape
Increase rigidity of the membrane
Increase adhesiveness
Increase virulence of disease
Membrane alteration
Infected
Non-infected
Ineffective erythropoiesis
Hypoglycemia
Will increase glucose use
Impaired glucose production
Inhibit gluconeogenesis
From non-sugar precursors
Lactate
Pyruvate
Carbon skeletal gluconic amino acids
After returned from Angola
decreased appetite
discomfort on lying down
irritability
neurasthenia
profuse sweating
2-4 hours
fever gradually drops
watery stools (diarrhoea)
tissue injury in the liver, pancreas and intestine
dehydration
disorders of the digestive system
no vomiting
High fever
on and off high fever at irregular interval (40 ºC)
fever pattern
In P. falciparum infection, fever continuous during the initial days
poorly delineated paroxysms that may extend irregularly
paroxysms get better established and are characterized by a sharp rise in temperature to peak value (39-41.5ºC) at the onset of a paroxysm
1 more item...
Cold stage
Hot stage
Sweating stage
high grade fever 40°C
2-6 hours
shaking chills, rigors, fever
sweating
15 minutes to 1 hour
general malaise
microvascular sequestration of parasitized red blood cells
decreasing oxygen delivery
obstructed blood flow and tissue hypoxia
severe falciparum malaria
Skeletal muscle necrosis
sequester of infected erythrocytes
microcirculatory obstruction
Rhabdomyolysis
muscle injury or death
kidney failure
intense myoglobinuria
Plasmodium parasites increases cytokines levels (such as tumour necrosis factor, TNF)
formation of highly damaging free radicals
damage and muscle weakness.
Much lower levels of RNA and protein contents were found in skeletal muscles
increase in protein degradation or enhanced catabolism
produced approximately half of the normal contractile force, fatigued significantly more, and recovered significantly less from fatigue
decrease in content of key contractile proteins
On 3rd Day Hospital
Obtundation
Definition: reduced level of alertness or consciousness
Complication: Cerebral Malaria
Caused by causes by parasitized red blood cells (pRBCs) sequestered in cerebral micro-circulation
cause neural dysfunction and lead to obtundation.
Pale
Complication: Anemia
Bone marrow dysfunction in malaria
Parasite able to replicate in this organ
Bone marrow unable to produce blood cells.
reduced Red Blood Cell Deformability (RBC-D)
RBC incapable of responding to shear stress in the circulation
RBC unable to perform their efficient passage through capillaries.
icteric
Definition: having jaundice
Cause
Direct
Malarial hepatitis
Hepatocellular dysfunction ranging from hyperbilirubinemia
Intravascular hemolysis of parasitized RBC
Indirect
G6PD-related hemolysis
Patients who had hyperbilirubinemia were considered to be having icteric.
Profuse sweating
Immune response to fever
Act as cooling agent
Tachypnea
Complication: Pulmonary oedema
Parasitize red blood cells
The alveolar capillary membrane's permeability increases
Acute Respiratory Distress Syndrome (ARDS) may occur
Definition: breathing rate that is higher than the normal breathing rate
Hemodynamic instability
Defintiion: the flow of blood within the organs and the tissues of the body.
Cause: cytoadherence
Change the shape of blood.
increased rigidity of the membrane
Increase adhesiveness
Learning Outcome 4 : Diagnosis
Risk factors
Demographic
44 Year old Man
Schwartz et al., in 2001, age was significantly allied with the risk for developing severe disease.
The reason for the increased vulnerability at the age of >40 years is not clear, but patients aged >40 years used prophylaxis less than did younger patients.
May be due to the underlying medical conditions of the aged patients.
Born in Angola, Lives in Gabon
Angola is among the ten countries with the highest number of malaria cases and deaths
Incidence of Plasmodium falciparum Malaria in Angola is at the peak of 90% of the malaria infection.
Gabon, a country along the Atlantic coast of Central Africa is also known hyperendemic for malaria.
The most dominant species in Gabon is P. falciparum
Building Construction Worker
In a study by Degarege et al. in 2019, lack of education, low income, low wealth, living in poorly constructed houses,farming may increase risk of Plasmodium infection
Dark Skin
According to Centres for Disease Control and Prevention (CDC), 2021, most of the cases in the United States are in travelers and immigrants returning from parts of the world where malaria transmission occurs, including sub-Saharan Africa.
Sub-Saharan Africa known to have dark skin.
Geographic
According to Association for Medical Assistant to Travellers (IAMAT),2021, multidrug resistant P. falciparum malaria is present in all areas that is high-rate area of malaria in Angola.
Angola is facing chloroquine drug resistance, therefore, the used of first line treatment using chloroquine does not work to treat malaria that comes from Angola.
Behavioral
Malarial infection also can also result from the use of blood contaminated through needle.
Patient is an illicit drug user, thus, is might be one of the supportive risk factor,infection although malaria is very rarely acquired by needle sharing among intravenous drug users (IVDUs).
In a study conduct by Alavi et al. in 2010, 27.6% were positive for Plasmodium falciparum, and all of them had shared needles and syringes in the days before their illness.
Medical Hazard
Patient did not take any precaution upon travelling to Angola which is an endemic malarial country.
Angola is also facing chloroquine drug resistance therefore; this increase the risk of the patient to be infected with Plasmodium falciparum malaria.
. Due to Angola is a chloroquine drug resistance country, prophylaxis treatment that should be taken by patient is ACT treatment to strengthen the immunity of the traveller himself.
Clinical manifestation
Splenomegaly
After repeated exposure to malaria due to immunological over stimulation
Changes in red blood cell
Causes anema associated with splenomegaly
Fever
Fever and chills are associated with the rupture of erythroctic-stage schizonts
Peripheral blood smear
Irregular RBC shape and hemolysis
Due to antibody sensitization or other physicochemical membrane changes.
Thrombocytopenia
The most common complication in Plasmodium falciparum malaria
Signs and symptoms
After visit to Angola
Fever pattern
Having a fever pattern that goes on and off ; fever paroxysm
General malaise
Malaria can also cause discomfort in the whole body
On admission
Lethargic
Destruction of RBCs and consumption of glucose by Plasmodium parasites
Dehydrated
A study case suggests 82% of diarrhoeal malaria caused by Plasmodium species
Seizure
Neurological problems that can be seen in cerebral malaria
Splenomegaly
The key organ to eliminating senescent red blood cells (RBCs), pathogenic bacteria, and Plasmodium-parasitic RBCs.
On 3rd hospital
Obtundation
Complicated malaria would usually lead to impaired consciousness
Pale skin
Causing anemia which leads to low amounts of haemoglobin
Plasmodium parasites will utilise the bone marrow to reproduce
Icteric
The occurrence of jaundice is common in malaria
Learning Outcome 3:
Clinical Manifestation
Before treatment
Physical exam
Abdominal exam
Physical examination: press on the stomach under the left ribcage.
Can cause loss of appetite, feeling discomfort or pain behind the left ribs pain, anemia and fatigue.
Splenomegaly: enlargement of the spleen.
Fever
Recurrent fever
On and off 40°C at irregular intervals
Lab test
Platelet
27,00 platelets per microliter of blood (thrombocytopenia)
Fatigue, enlarged spleen, and blood or stools
WBC
7200 microliter of blood
Haemoglobin
11.9 grams per deciliter (anemia)
Fatigue and fever
Mild liver cytolysis without hyperbilirubinemia
Cytolysis means the disintegration or dissolution of a cell.
Cytolysis syndrome in liver disease is marked by a greater rise in ALT activity compared to AST
AST/ALT ratio can be used to assess the degree of liver damage
Marked increase which is an acute increase is usually >15 times the upper limit of normal values
Minor to moderate, typically chronic increases is usually 10 times the upper limit of normal values
Peripheral blood smear
RBC with irregular shape & hemolysis
Anemia, fatigueness, pale skin, fever, jaundice, enlargement of spleen, seizures and unexpected or severe infection
After treatment
Physical examination
Tachypnea
Normal breathing rate is 12 - 20 breaths per minute. More than 20 breaths per minute is considered tachypnea
Physical examination: Blue-tinged fingers or lips which are called peripheral or central cyanosis respectively and/or usage of auxiliary muscles or chest muscles to breathe
In malaria, the earliest sign that can be observed in patients during physical examination is tachypnea followed by peripheral cyanosis, wheezing on expiration and bibasilar crackles
Hemodynamic instability
The respiration rate, pulse, blood pressure, urine output, organ perfusion, toe-temperature gradient, and capillary refill time of a patient are all being checked.
Referring to any instability in blood pressure that might lead to insufficient blood supply to organs
Lab test
Low hemoglobin with hyperbilirubinemia
Hyperbilirubinemia: Elevated serum of plasma concentration of bilirubin concentration that is more than the normal range, can cause yellow discoloration of the eyes and skin
3 possible factors can cause hyperbilrubinaemia in malaria:
Intravascular hemolysis
Disseminated intravascular coagulation
Rarely, 'malarial hepatitis'
Hemoglobin level falls down to 4.8 g/dL, which is even worse than when first admitted
Learning Outcome 1: Risk Factors
Segmented into
Demographic
Dark Skin
44 Year old Man
Building Construction Worker
Born in Angola, Lives in Gabon
Geographic
Visit Angola recently (2 weeks ago)
Sub-Saharan Africa
Endemic to malaria diseases
P. falciparum mosquito
Resistant to chloroquine
Behavioral
No alcohol, smoking, and sexual risk contacts
Illicit drug use
Medical Hazard
Not Taking Prophylaxis
Visited malaria endemic area without protection
Prophylaxis should be used be visited the country
Usually Chloroquine as prophylaxis (since resistant)
Recommended:
Atovaquone-proguanil
Doxycycline
Mefloquine
Tafenoquine
Caused by
