Malaria in children 2021

Classification, Epidemiology, Etiology�Clinical Features, Complications, Management�Prognosis and Prevention

1. Malaria in children
Classification, Epidemiology, Etiology
Clinical Features, Complications, Management
Prognosis and Prevention
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics(2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

2. (God speaking to Prophet Muhammad (PBUH)
The month of Ramazanis blessed because The Holy Quran was revealed in
this month; a book of guidance for all the mankind, which has clear signs
to guide and to differentiate the right and wrong
The Holy Quran surah Al-Baqara2:185
Al-Quran

3. Case Scenario
•A 4 year old child presents with fever for the last 3
days.
•He also vomits one or two times daily.
•On examination, he has a temperature of 102F.
•What may be the likely diagnosis ?
•How will you further evaluate this child to make a
diagnosis and decide about management ?

4. Common causes of Fever in Children
•Acute bronchitis
•Acute tonsillitis
•Pneumonia
•Acute gastroenteritis
•Acute hepatitis
•Typhoid fever
•Malaria
•Bacteremia / Septicemia
•Meningitis

5. Further evaluation -History
•How much Fever was present on first day ?
(gradual or sudden rise?)
•Does the child have associated symptoms of ?
-runny nose, cough
-sore throat, ear pain
-diarrhoea
-Headache, convulsions / fits
•Does the child have pain anywhere in the body ?
•History of Contact with patients of ARI, measles, other infections ?
•History of exposure to mosquitoes ?

6. Case Scenario –History
•A 4 year old child presents with fever for the last 3 days. He also
vomits one or two times daily. On examination, he has a
temperature of 102F.
•Mother says child does not have runny nose, cough,
diarrhea or fits.
•He does not feel pain
•Child was all right three days ago when he suddenly
had abrupt onset of high fever
•What may be the possible cause of this fever ?

7. Further evaluation -Examination
•Skin rashes
•Jaundice
•Face -mumps
•Oral ulcers
•Respiration –rate / indrawing/ auscultation
•Lymph nodes, Liver, spleen
•Signs of meningeal irritation
•Throat, ears
•Any swelling anywhere / abscess

8. Case Scenario -Examination
•A 4 year old child presents with fever for the last 3 days. He also vomits
one or two times daily. On examination, he has a temperature of 102F.
•Mother says child does not have runny nose, cough or diarrhoea. Child
was all right three days ago when he suddenly had abrupt onset of high
fever which comes down with antipyretics but rises again after a few hours
•On examination, any skin rashes or jaundice are not
present.
•Respiratory rate is 38 per minute.
•Chest auscultation and throat examination are normal.
Any lymph nodes or viscera are not palpable
•SOMI are negative.
•What is the most likely diagnosis ?

9. MALARIA
An infectious disease
caused by
Plasmodium (protozoa)
and characterized by
fever and anemia

10. ETIOLOGY
•Plasmodium(obligate intracellular protozoa)
•Common species -
•Plasmodium vivax
•Plasmodium falciparum
•Rare species –
•Plasmodium ovale
•Plasmodium malariae
•Plasmodium knowlesi

11. Malaria –Epidemiology
•Malaria is an important cause of global child deaths,
most of which occur due to P.falciparumin Africa
•Malaria is endemic in Pakistan
•More common in Sindh and Baluchistan
•Geography : areas near water reservoirs
•Season : Warm
•Usual age = all age groups
= more common in 6 months to 3 years

12. Transmission of Malaria
Arthropod –borne (insect vector)
Anopheles Mosquitoes (mosquito bite through skin)

13. Malaria –Transmission
•Source of parasite –Infected person
•Transmission –Mosquito bite(arthropod -borne)
--Blood Transfusion (rare)
•Host –susceptible child / adult
•INCUBATION PERIOD –10 –17 days
•Infectivity Period: variable

14. Plasmodia in Mosquito and Humans

15. Life cycle of Malarial Parasite
•Mosquito bite entry of Sporozoitesin blood
•Sporozoitesenter Hepatocytes (pre-erythrocyticand exo-
erythrocyticcycles in liver)
•After (7 –14 days) Merozoitesreleased in blood and enter
RBC (asexual cycle in humans)
•Asexual reproduction cycles continue in RBCs with formation of
Schizontand release of merozoitesin blood with each cycle
•Some Merozoitesform Gametocytes which are taken up by
mosquito with formation of zygote and sporozoites(sexual cycle in
mosquito)

17. Proliferation of Malarial Parasite
•Mosquito bite (100 Plasmodia introduced)
•Exo-erythrocyticphase (multiply to 10,000)
•Erythrocyticphase (100,000,000,000,000)

18. Clinical Features
and
Diagnosis

19. CLINICAL FEATURES
•Fever
-moderate to high
-daily / alternate day / irregular
•Other symptoms
-fatigue
-headache
-vomiting
-myalgias

20. Initial Clinical Diagnosis of Malaria
•Initial DIAGNOSIS of MALARIA is clinical
•Abrupt rise of fever
•moderate to high Fever
•Alternate day fever (seen in P. vivaxafter few days)
•Chills and sweating are neither required for diagnosis
nor specific for malaria in children
•History and examination does not show any localising
sign / any other obvious cause of fever

21. Diagnosis of Malaria
•MALARIA is suspected clinically
•Diagnosis is confirmed by detection of malarial parasites in blood
•MP –(looking for malarial parasite in blood)
Thick and thin blood smear preparation
(requires time and expertise)
•WHO Recommended method –RDT (Rapid Diagnostic Test) for
Malarial Antigen detection in blood (immunochromatographic
method)

22. Plasmodium vivaxin RBCs

23. Plasmodium falciparum in RBCs

24. RDT (Rapid Diagnostic Test) for Malaria
•WHO Recommended method –RDT (Rapid Diagnostic Test)
•Malarial Antigen detection in blood (immunochromatographic
method)

25. Complications of malaria
•Anemia
•Jaundice
•Splenomegaly
(more common with repeated infections)
•Relapses (P. vivax)
(due to exo-erythrocytichepatic cycle)

26. Serious Complications of Falciparum Malaria
•Cerebral malaria
–Hypoxia of brain due to vascular capillary obstruction by
parasitized RBCs
–High fever, unconscious, fits, neurological deficits
•Blackwater fever
–Severe intravascular hemolysis
–Hemoglobinuria, renal failure
•Algid malaria
–Hypotension, circulatory collapse, shock
•Hypoglycemia

27. Cerebral Malaria

28. Cerebral Malaria –intracranial hemorrhages

29. Cerebral Malaria
Unconciouschild -Intra-cerebral and retinal hemorrhages

30. Management
of
Malaria

31. MANAGEMENT
•Antipyretics –paracetamol, ibuprofen
-tap water sponging
•Hydration –oral / IV fluids
•Nutrition –small frequent oral / gavage (tube) feeds
•Management of complications

32. Antimalarial drugs
•Chloroquine
•Pyrimethamine–sulfadoxine
•Mefloquine
•ACT (artemisinincombination therapy) –
artemether+ lumefantrine
artesunate+ amodiaquine
artesunate+ mefloquine
artesunate+ sulfadoxine-pyrimethamine
dihydroartemisinin+ piperaquine
•Quinine

33. Choice of Anti-malarial drugs depends upon
•Age of patient
•Clinical presentation
•Infecting species –Vivax/ Falciparum
•Local resistance pattern
•Adverse effects

34. Plasmodium vivaxmalaria (uncomplicated)
•Chloroquine (if known to be chloroquine -sensitive)
•ArtemesininCombination Therapy
(artemether+ lumefantrine)
•Pyrimethamine+ Sulfadoxine(more adverse effects)
•Mefloquine(resistant cases)

35. Plasmodium falciparum malaria (uncomplicated)
•ArtemesininCombination Therapy
(artemether+ lumefantrine)
•Pyrimethamine+Sulfadoxine+ Mefloquinecombination
•Quinine Sulphate (oral)

36. Cerebral Malaria
Plasmodium falciparum (complicated)
•Artesunate/ ArtemetherIV or IM therapy
•Quinine dihydrochlorideIV / Oral

37. PREVENTION
Individual
•Personal protection –Mosquito nets / repellants / sprays
•Chemoprophylaxis –anti-malarial medicine to prevent proliferation
of parasites after entry in blood –
--Chloroquine weekly (chloroquine –sensitive areas)
--Mefloquineweekly (chloroquine –resistant areas)
Community
•Destroy Mosquito breeding places
--Pesticides
--Drain stagnant water

38. Visceral
and
Cutaneous
Leishmaniasis

39. Leishmaniasis

40. Visceral Leishmaniasis(Kala -Azar)

41. Visceral Leishmaniasis(Kala -Azar)

42. Cutaneous Leishmaniasis(Oriental sore)

43. Textbook of Paediatrics-6th edition 2021
Pakistan Pediatric Association
•Written by senior teachers of
Pediatrics in Pakistan
•Provides up-to-date essential
information on Pediatric
diseases and Child Health
•Published by Paramount
Books, Pakistan
•www.paramountbooks.com.pk