'MALARIAL FEVER'.pptx by Dr. Humna Uzair

Malarial fever, caused by various species of the Plasmodium parasite transmitted through the bite of infected Anopheles mosquitoes, manifests in distinctive stages and symptoms.

1. MALARIAL FEVER PLASMODIUM dr.hamnA UZAIR

2. SYSTEMIC PROTOZOAL INFECTION MALARIAL FEVER IS A SYSTEMIC PROTOZOAL INFECTION CAUSED BY PLASMODIUM SPECIES TRANSMITTED THROUGH BITE OF FEMALE ANOPHELES MOSQUITO. TYPES OF PLASMODIUM---------------- 1- PLASMODIUM FALCIPARUM [MOST LETHAL] 2- PLASMODIUM VIVAX [MOST COMMON] 3- PLASMODIUM OVALE 4- PLASMODIUM MALARIAE 5- PLASMODIUM KNOWLESII

3. LIFE CYCLE OF PLASMODIUM RECRUDESCENCE OF FEVER IN P. FALCIPARUM, P. MALARIAE AND P. KNOWLESII RESULTS FROM MULTIPLICATION OF PARASITES IN RED CELLS THAT HAVE NOT BEEN ELIMINATED BY TREATMENT OR IMMUNE SYSTEM.

4. Signs and Symptoms of P.Falciparum - Onset with malaise, headache and vomiting. - FEVER WITH CHILLS - Cough and mild Diarrhea are also common. - Jaundice - Anemia - Hepatospleenomegaly - Parasite can preferentially bind to placental chondroitin sulfate and can cause IUGR or Abortion in pregnant females.

5. Signs and Symptoms of Cerebral Malaria - Cerebral malaria is mainly caused by P. Falciparum. - Patient presents with symptoms ranging from delirium, seizures or coma. - Childern can die rapidly without specific symptoms other than fever. TREATMENT: INJ. ARTESUNATE IV/IM------2.4 MG/KG/DOSE AT 0,12,24 THAN ONCE EVERY DAY FOR 7 DAYS. REST OF TREAT SYMPTOMATICALLY

6. Signs and Symptoms of P. Vivax and P. Ovale - Several days of continued fever followed by bouts of fever on alternate days. Fever starts with rigors. P. MALARIAE AND P. KNOWLESII------ - Alternate day fever with rigors and chills - Chronic P. Malariae causes Glomerulonephritis and long term nephrotic syndrome in children.

7. PREMUNITION PARTIAL IMMUNITY BASED ON HUMORAL ANTIBODIES THAT BLOCK MEROZOITES FROM ENTERING RED CELLS OCCURS IN PREVIOUSLY INFECTED INDIVIDUALS. A LOW LEVEL OF PARASITEMIA AND LOW GRADE SYMPTOMS THAT RESULTS, IS CALLED AS PREMUNITION.

8. COMPLICATIONS - BLACK WATER FEVER from GLOMERULONEPHRITIS due to formation of knob proteins in vascular endothelium. - SPLEENOMEGALY. - SPLENIC RUPTURE. - CEREBRAL MALARIA due to formation of knob proteins in vascular endothelium. - HYPOGLYCEMIA due to consumption of glucose by malarial parasite. Spontaneous bleeding and coagulopathy. - HYPOTENSION due to peripheral vasodilation resulting from vasoactive materials produced by malarial parasite.

9. COMPLICATIONS Cont ….. JAUNDICE/ HYPERBILIRUBINEMIA/ HEMOGLOBINEMIA/ HEMOGLOBINURIA - HYPERKALEMIA IN IST FEW DAYS OF FEVER RESULTING FROM CELLULAR LYSIS - LACTIC ACIDOSIS THROUGH ANAEROBIC GLYCOLYSIS IN PARASITE ITSELF AND INHIBITION OF OXIDATIVE METABOLISM IN THE HOST IN THE CONTEXT OF ONGOING INFLAMMATORY RESPONSE CAUSING PROTON [H+] ACCUMULATION LEADING TO METABOLIC ACIDOSIS. - HYPOKALEMIA LATER ON FROM A COMBINATION OF INTRACELLULAR TRANSLOCATION OF POTASSIUM AS A COMPENSATION TO ACIDOSIS AND URINARY POTASSIUM LOSS . HYPOKALEMIC PERIODIC PARALYSIS

10. CASE PRESENTATION A 34-YEAR-OLD FEMALE WITH GESTATIONAL AMENORRHEA OF 6 MONTHS PRESENTED WITH C/O HIGH GRADE CONTINUOUS FEVER FOR 1 WEEK WITH CHILLS ASSOCIATED WITH NAUSEA. THE FEVER WAS NOT ASSOCIATED WITH VOMITING, DIARRHEA OR ANY OTHER SYSTEMIC SYMPTOMS. THE PATIENT HAD BEEN TAKING ANTIPYRETICS AND UNKNOWN ANTIBIOTICS BY LOCAL DOCTOR. O/E: TEMP---- 104’F PULSE---- 162/mint BP---- 90/50mmHG RR---- 24/MINT

11. - BSR---- 139mg/dl SPO2----99% HER RESPIRATORY AND CARDIAC EXAMINATION WAS UNREMARKABLE ABDOMEN SOFT AND TENDER IN LEFT HYPOCHONDRIAC REGION NO HEPATOMEGALY SPLEENOMEGALY +VE 5 TO 6 CM BELOW THE COSTAL MARGIN THE NEUROLOGICAL EXAMINATION WAS ALSO UNREMARKABLE PATIENT ADMITTED IN THE HOSPITAL AND BLOOD SAMPLES WERE SENT. THE RESULTS REVEALED S. POTASSIUM VALUE OF 2.3 mEq /L. THE ECG CORRESPONDINGLY SHOWED FLATTENED T-WAVES AND THE PRESENCE OF U-WAVES MALARIAL ICT TEST WAS NEAGATIVE AS WELL AS MALARIAL THICK FILM EXAMINATION i.e NO PARASITE HAD BEEN SEEN ON SLIDE.

12. DIAGNOSIS TRIAD OF MALARIA DIAGNOSIS HAD BEEN MADE ACCORDING TO THE FOLLOWING TRAID: 1- FEVER 2- ANEMIA 3- SPLEENOMEGALY

13. PATIENT HAD BEEN GIVEN POTASSIUM REPLACEMENT AT RATE OF 25mEq/HOUR. ANTIPYRETICS AND IV OMEPRAZOLE PATIENT DISCHARGED ON CO-ARTEM 80/480 1 PO OD FOR 7 DAYS WITH ADVISE ON TAKING POTASSIUM RICH DIET INCLUDING BANANAS AND DATES. PATIENT REVISITED ON 3 RD DAY WITH SYMPTOMS OF NAUSEA. HOWEVER FEVER WAS SETTLED. BLOOD SAMPLE FOR SERUM POTASSIUM HAD BEEN SENT. SERUM POTASSIUM WAS 3.9 mEq /L, C/O NAUSEA ADRESSED AND ADVISED TO CONTINUE THE TREATMENT. .

14. WHO RECOMMENDED TREATMENT ARTEMINISIN BASED TREATMENT WHICH COMPRISES OF ARTEMETHER+LUMEFANTRINE----- PEDIATRIC DOSE OF ARTEMETHER---- 3.2mg/kg IM than 1.6 mg/kg daily for 5 days DOXYCYCLINE AND ARTEMETHER SHOULD BE AVOIDED IN EARLY PREGNANCY. ALTERNATIVES INCLUDE: 1- QUININE 600 MG TDS FOR 5 TO 7 DAYS TOGETHER WITH DOXYCYCLINE 100 MG 1 PO BD FOR 7 DAYS OR CLINDAMYCIN 450 MG 1 PO TDS FOR 7 DAYS --------- PEDIATRIC DOSE of QUININE-----30MG/KG/DAY PO IN 3 DIVIDED DOSES OR LOADING DOSE OF 20 MG/KG THAN 10 MG/KG/DOSE EVERY 8 HOURS FOR 3 TO 7 DAYS.

15. . 2- CHLOROQUINE 600 MG BASE FOLLOWED BY 300 MG BASE IN 6 HOURS AND THAN 150 MG BASE TWICE DAILY FOR 2 MORE DAYS ------PEDIATRIC DOSE 10MG/KG LOADING DOSE FOLLOWED BY 5 MG/KG AFTER 6, 24 AND 48 HOURS. HYPNOZOITES FORM IS DESTROYED BY PRIMAQUINE 15 MG DAILY FOR 14 DAYS OR 0.5MG/KG PO OD FOR 14 DAYS

16. TREATMENT OF SEVERE MALARIA PARASITE COUNT OF GREATER THAN 2 % IS CONSIDERED AS SEVERE MALARIA OR WITH COMPLICATIONS INTRAVENOUS ARTESUNATE GIVEN AS 2.4 mg/kg AT 0, 12 AND 24 HOURS AND THEN ONCE DAILY FOR 7 DAYS QUININE SALT LOADING DOSE OF 20mg/kg OVER 4 HOURS UPTO MAX OF 1.4 GRAM FOLLOWED BY MAINTAINENCE DOSE OF 10mg/kg OVER 4 HOURS FOR 2-3 TIMES DAILY UNTILL PATIENT START TAKING ORALLY.

17. CHEMOPROPHYLAXIS CHLOROQUINE IS THE DRUG OF CHOICE AND IS GIVEN ONCE WEEKLY STARTING 1-2 WEEKS BEFORE GOING TO ENDEMIC AREA AND ENDING 4 WEEKS AFTER LEAVING ENDEMIC AREA. DOSE IS 300MG BASE WEEKLY OR 5 mg/kg DOXYCYCLINE 100 mg DAILY MEFLOQUINE 250 MG WEEKLY

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