Malaria

Introduction
mal aria = bad air (Italian word)
3.3 billion people (41%) are at risk
Every 30 seconds a child dies of
malaria
World Malaria Day: 25th April

Etiology
Organisms:
Plasmodium
Plasmodium
Plasmodium
Plasmodium

vivax
ovale
malariae
falciparum

Vector:
Female Anopheles mosquito
( A. culcifacies, A. stephensi, A. minimus)

Mode of Transmission:
Mosquito bite
Blood transfusion
Contaminated needles
Vertical transmission

Prevalance of Malaria
Splenic Index:
Rate of palpable spleen in children between
the ages of 2-10 years.
<10%: low incidence
>50%: hyperendemic
>75%: holoendemic
Parasite Rate:
Percentage of children between 2-10 years
who show malarial parasites in their blood

Malaria Life
Cycle
Life Cycle

Sporogony
Oocyst
Sporozoites
Mosquito Salivary
Gland

Zygote

Exoerythrocytic
(hepatic) cycle

Gametocytes

Erythrocytic
Cycle

Schizogony

Hypnozoites
(for P. vivax
and P. ovale)

Pathophysiology
Fever
Release of merozites

Anaemia
Hemolysis
Sequesteration in spleen
Bone marrow suppression

Organ Failure

Tissue anoxia
Cytoadherance of erythrocytes to the endothelium

Hypoglycemia/ Acidosis
Anaerobic metabolism

Immunity
Innate:
Hemoglobin S sickle cell trait or disease
Hemoglobin C and hemoglobin E
Thalessemia and
Glucose 6 phosphate dehydrogenase
deficiency (G6PD)
Absence of Duffy coat antigen

Acquired:
Transferred from mother to child
Protects in first 3 mnths

Clinical Features
Incubation Period
P.
P.
P.
P.

falciparum = 9-14 days

vivax = 12-17 days
ovale = 16-18 days
malariae = 18-40 days

Prodrome
Headache, anorexia, myalgia, fever, joint
pain

 Febrile Paroxysms
Coincides with the release of schizonts
P. vivax/ovale = 48 hrs
P. malariae = 72 hrs

COLD STAGE:
Chills, rigor
Headache, nausea, vomitting

HOT STAGE:
Dry, flushed skin
Rapid breathing

SWEATING STAGE:
Fever decreases by crisis

 Non-immune children
High grade fever
Nausea, vomiting, diarrhoea, anorexia
Prostration
Pallor, cyanosis
Hepatosplenomegaly

High-endemic zone
Milder symptoms
Markedly enlarged liver and spleen
Early manifestations of complications

 RECRUDESCENCE:
Occurance after primary attack
Survival of erythrocyte forms in the blood
stream
P. malariae, P. falciparum

RELAPSE:
Release of merozoites from exo-erthrocytic
cycle
P. vivax, P. ovale

RECURRENCE:
exo-erythrocytic forms infect erythrocytes,
separate from previous infection (all species)

Congenital malaria
Occur in endemic areas
Abortions, stillbirth, prematurity, IUGR
Present in 10-30 days of life
fever
Restlessness, drowsiness
Pallor, jaundice
Poor feeding, vomiting
hepatosplenomegaly

Complications
Cerebral malaria:
sequesteration of capillaries with parasitized erythrocytes
thrombosis of cerebral vessels

Fatality rate = 20-40%

Parasitemia >5%
Altered sensorium, delirium, hallucination
Headache, Deep coma
High fever
Seizure, Hemiplegia
UMNL features
CSF= Normal
Hypoglycemia has bad prognosis

 Renal failure:
Decrease in renal blood flow
Acute tubular necrosis
Deposits of hemoglobin in renal tubules

Blackwater Fever:
Severe hemolysis
Hemoglobinuria
Renal failure

 Algid malaria:
Overwhelming infection of P. falciparum
hypotension, hypothermia
Circulatory collapse, shock

Anemia
Thrombocytopenia
Hypoglycemia
Pulmonary oedema
Splenic rupture

Diagnosis
Peripheral Smear (gold standard)
Thick smear
Thin smear

Quantitative Buffy coat

 Rapid Diagnostic tests

OptiMAL test
Immunochromatographic test
Detects parasite LDH

PCR
Immunofluroscence Assay
Bone Marrow Aspiration
CBC, RBS, RFT, LFT, PT, Urine RME

Differential Diagnosis

Typhoid
Anicteric hepatitis
Septicemia
UTI/ Pyelonephritis
Pnemonia
Liver abscess
Infective endocarditis
Meningitis/
Encephalitis
Shock

Kala-azar
Tuberculosis
Leukemia
Collagen vascular
Disease

Treatment
Uncomplicated Malaria
Chloroquine Phosphate
10mg (base)/kg stat
5mg (base)/kg at 6, 24 and 48 hrs

Primaquine
0.75mg/kg on D1 (P. falciparum)
0.25mg/kg for 14 days (P. vivax, ovale)

 Second line drugs

Artesumate Sulphapyrimethamine
Oral Quinine
Mefloquine
Atovaquone- proguanil
Clindamycin
Doxycyclin

 Severe Malaria:
Immediate Management:
ABC management
Assess GCS
Correct hypoglycemia, dyselectrolytemia
Mx of unconscious patient
Mx of raised ICP

 Antimalarial therapy:
Quinine dihydrochloride
20mg (salt)/kg in 5% Dx over 4hrs IV
10mg (salt)/kg over 4hrs every 8hrly
Once the child can take orally;
Oral Quinine: 10mg/kg/dose 8hrly for
7days

Artesumate (IV)
2.4mg/kg stat then 1.2mg/kg at 12, 24 hrs

Artemether (IM)
3.2mg/kg stat the 1.6mg/kg at 12,24 hrs

 Supportive care:
Antibiotics
Anticonvulsants
Blood transfusions
Dialysis
Fluid and Electrolytes balance
Ionotropic support
Correction of hypoglycemia
Correction of raised ICP
Mechanical ventilation

Prevention
Reducing exposure to infected
mosquitos
Insecticides
Mosquito repellants and creame
Permethrin Rxed mosquito net
Full sleeved clothings
Drainage of stagnant water bodies
Gambusia fish

 Chemoprophylaxis
Chloroquine
5mg (base)/kg every weekly
1-2 weeks before and 4 weeks after
entering an endemic zone

Chloroquine resistant: Mefloquine

Vaccination
Under development
RTS,S (Mosquirix)