Assignment 2

Travel Medicine
This is a case of fever in returned travellers. Fever is a common
symptom and thus has a long list of potential diagnosis, ranging from
common infection to unusual and serious infection. Details about
geographic area of travel, details of activities (animal bite/sexual
activities/environmental exposure), preparations before travel
(prophylaxis antibiotics and vaccinations) and time of exposure
(incubation period) are important to exclude some infection from the
differential diagnosis list.
This patient has recently travelled to highly endemic area of
malaria and his symptoms may suggest of the disease. Other possible
differential diagnoses are Dengue Fever, Typhoid and Leptospirosis
should be kept in mind.
Malaria is an ancient disease in India. Known as the king of
disease, malaria was estimated to cause 30 million cases and 200,000
deaths annually in India. An estimated 95% population lives in area
where malaria transmission has been reported. Malaria where in
Malaysia is confined in rural/ forest area, is differ in India. Malaria
transmission is accelerated by widespread vector breeding habitats
created through economy development (such as upcoming townships,
urban agglomerations, port cities and agriculture fields) besides Indias
climatic conditions of largely a rainfall phenomenon.
Malaria is a mosquito-vector born disease. Anopheles Culcifaces is
the commonest vector of rural malaria in India (about 75%). An.
Stespesis is an invasive species that invades urban environment with
drain water to support breeding. Of few malaria parasites, Plasmodium
Vivax and P.Falciparum are prevalence in India, each of 80-85% and 1015%.
The above patient has symptoms and travelled to a place where
Malaria is common. The WHO guidelines for the treatment of Malaria
published in 2010(2nd Edition) provides evidence-based recommendation
on the case management of Malaria and also framework for national
treatment protocols for Malaria control; taking into account local anti

Malaria drug resistance pattern and health service capacity. Summary of

key recommendation are as follow;
Treatment for uncomplicated P.Falciparum Malaria
a) Artemisin-based combination therapies (ACT) should be used is
preference to sulfadoxine-phrimethamine (SP) plus amodiaquine (AQ).
b) ACTs should be given at least for 3 days
c) Dihydroartemisin plus piperaquine(DHA+PPQ) is the first line
treatment worldwide.
d) Addition of single dose primaquine to ACT as an anti gametocyte
medicine.
Treatment for uncomplicated P.Vivax Malaria
a) At least 14 days course of primaquine is required for radical treatment.
b) In area with chloroquine resistance, ACTs are recommended.
c) Chloroquine plus primaquine is the treatment of choice.
Malaria diagnosis
Prompt parasitological confirmation by microscopy or Rapid
Diagnostic Test (RDT) is recommended in suspected malaria cases
before treated is started.
WHO recommends that in the settings where risk of malaria highly
prevalent ( based on epidemiology of the country), clinical diagnosis
should be based on history of fever in previous 24 hours and /or
presence of anaemia. This patient has bout of high fever for three days,
pallor and travelled to Indias hinterlands; a highly endemic place.
In all settings, the clinical suspicion should be based on
parasitological diagnosis. Two routinely used methods are light
microscopic and RDT. In area where two or more species of Malaria are
common, light microscopic is needed to permit a species diagnosis. This
patient is thereby needs light microscopic blood test (thin and thick blood
film for Malaria parasite) as P.Vivax and P.Falciparum are common.

Resistance to anti-Malaria has been documented for all

Falciparum species. However, P.Vivax remains sensitive to choloroquine
in India. Resistance varied considerably in all currently used antiMalarias in P.Falciparum in India. Clinically assessment and blood test is
therefore needed to exclude sensitivity to anti-Malaria drugs.
As this patient has no clinical symptoms of severe Malaria(end
organ damage such as cerebral Malaria, renal failure, Acute Respiratory
Distress Syndrome, severe anaemia) options of treatment is as above.