Transcript Diagnosis and management of complicated falciparum malaria Dr S

Management of
severe falciparum malaria
Dr SK Mishra,MD
Ispat General Hospital,
Rourkela 769005
India
Falciparum malaria is a
potentially fatal disease
Successful treatment
completely cures without
disability
Early diagnosis and prompt
treatment prevents fatal
complications
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Severe malaria
1. Cerebral malaria
2. Acute renal failure
3. ARDS
4. Severe anaemia (Hb < 5g%)
5. DIC
6. Haemoglobinuria
7. Hypotension, Shock
8. Hyperparasitemia
9. Repeated seizures
10. Hyperpyrexia
11. Haemolysis (Sr bil. >3 mg%)
Diagnosis of malaria
1. History and clinical features
* locality , travel history
* fever
* spleno-hepatomegaly
* presence of complications
2. Laboratory diagnosis
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* Drug history
* Anti malarials
* Blood transfusion
History of
- haemoglobinopathy
- diabetes
- alcoholism/ jaundice
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Specifically ask / look for
- fever with duration
- headache
- vomiting, diarrhoea
- urine output and colour
- cough / dyspnoea/ bleeding
- altered sensorium / seizures
- pregnancy
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Clinical examination
Pallor, icterus
bleeding signs
early signs of pulm oedema
consolidation
arrhythmia
hepatosplenomegaly
uterus
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CNS Examination
Sensorium /coma score
- Glasgow coma score
- Blantyre coma score
- decerebration
Pupils, Fundus examination
Neck stiffness
Plantar reflex
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Laboratory diagnosis

Microscopy
 Immunological tests
 Antigen capture tests
 Antibody detection tests
 QBC test
 DNA probe
 PCR
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Microscopy
gold standard for diagnosis
thick smear: rapid diagnosis
thin : species identification
other advantage
- platelets, anaemia, toxic picture
If negative : repeat blood
test 6 hourly for 6 times
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Why parasites are not detected
at times in peripheral smear ?
a. sequestration in deep
vascular bed
b. partially treated patients
c. prophylactic antimalarial
treatment
d. inexperienced microscopist
e. poor quality staining
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Antigen capture tests
* Pf-ICT test
* Parasight-F test/ Malacheck
etc
Principle: dipstick antigen
capture assay employs a
monoclonal antibody detecting
the Pf.HRP-2 antigen in the
blood
Rapid, simple, sensitive test
Species specificity
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Antibody detection test
- RIA
- ELISA
antibody persists for a long
time so not helpful in
acute infection
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QBC test
Spinning blood in a specialised
capillary tubes in which
parasite DNA is stained with
acridine orange.
Detected by ultraviolet
microscope
Sensitive and specific (?) in
Experienced hands
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PCR test
Sensitive
Can identify different species
Takes 48- 72 hours
Expensive
Available in selected places
only
DNA Probes
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Cerebral malaria
Coma scoring
Exclude other causes of coma
1. ABC of coma care
2. Prompt institution of
antimalarials
3. Treatment of hyperpyrexia
4. Management of other
complications
5. Treatment of associated infections
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Antimalarial therapy
Parenteral therapy is a must as
rapid parasitecidal action is
warranted
Mainstay of therapy is Quinine
- Loading dose or not ?
- IV is the route of choice
- Donot reduce the dose in first 48
hours of quinine therapy
- 20% renal and 80% hepatic
clearance
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Quinine therapy
10 mg/ kg body weight over 4 hours
every 8 hourly in DNS or dextrose.
If therapy has to continue beyond 48
hours reduce dose to 2/3rd.
T 1/2 healthy subjects - 11 hours
uncomplicated patients 16 hours
cerebral malaria
- 18 hours
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Side effects:
Minor: cinchonism, tinnitus
deafness, vertigo, vomiting
does not require stoppage of
quinine treatment.
Severe: hypoglycemia, DIC,
haemolysis, arrhythmia,
thrombocytopenia etc.
These complications are rare.
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Artemisinine compounds
Rapid schizonticidal drug
Arteether (E-mal) inj
150 mg deep im od x 3 days
Artemether (Larither)
Inj 80 mg im bid x 3 days
or Inj. 80 mg bid first day
then od x 4 days
Artesunate (falcigo)
Unstable, to be prepared before
administration
2.4 mg/kg first dosem then 1.2 mg 12 hr
then daily for 3-4 days
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COMMON ERRORS IN
MANAGEMENT OF
SEVERE MALARIA
1.Failure to diagnose associated
complications such as bacterial
infections, eclampsia, Gram
negative septicemia etc.
2. Missed hypoglycaemia
3. Misjudgement of severity
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4.Errors of fluid and electrolytic
replacement
5.Errors in anti-malarial
chemotherapy
6. Delay in starting treatment
Unjustified withholding of
antimalarial drug for the fear of
toxicity e.g. Quinine in pregnant
women, in hypoglycaemia
-Inadequate dosage administration
-Failure to control the rate of IV
infusion
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7. Delay in considering obstetrics
intervention pregnant women
suffering from malaria
8.Missed / late diagnosis of ARDS,
acute pulmonary oedema
9 Use of inappropriate ancillary
therapies e.g. steroids, .
10. Delay in starting dialysis
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This lecture is prepared
exclusively for
Supercourse