INTERNAL MEDICINE DEPARTEMENT DUSTIRA HOSPITAL / MEDICAL FACULTY OF GENERAL ACHMAD YANI UNIVERSITY CIMAHI

Name Gender Religion Occupation Address

: Mr. Jumardin : Male : Islam : Army/Prada

Room : XI Age

No.Med.Rec

: 267618

: 20 years old

: United dormitory of Pusdik Armed - Cimahi

Sent by Date of examination (Co. ass) Date of treatment Date of Exit

: His Batallyon : May 22th 2011 : May 19th 2011 : May 26th 2011 : 17.30 p.m

Diagnosis: Doctor Co. ass : : Malaria Tropikal

A. HISTORY TAKING (Auto)

CHIEF COMPLAINT : Fever PATIENTS ILLNESS :

Since 9 days before entering the hospital, the patient complained of sudden high fever. fever preceded by chills about 30 minutes. after a fever for about 4 hours, the fever will come down then arise sweat a lot so that the patient becomes wet clothes.

after exiting the sweat, the patient felt his condition improved. complaint patient feels every day. Fever complaint was accompanied by weakness, headache, nausea without vomiting and poor appetite. Fever complaint was accompanied by that looks yellow eyes and a face that looks pale. Fever complaint was not accompanied by a decrease in consciousness or convulsions. Fever complaint was not accompanied by decreasement of urination, change of urines color that get blackish. And complaint of defecation wasnt found. Fever complaint was not accompanied by severe pain in the calf or to make the patient unable to walk, bleeding in the eye, and do not live in flood zones. Fever complaint was not accompanied by a cough for more than three weeks, sweat out in the evenings or drastic weight loss. Fever complaints was not accompanied by rapid breathing and or shortness of breath in time.

Patients had been visiting and living in malaria endemic area in Papua, from 1 January to 15 April 2011 to carry out tamtama education. patients did not drink malaria prevention medication before going to the venue. While in Papua patients have never experienced such complaints. This is the first complaint that experienced by the patient, and family no one has suffered from this disease. Before the patient entered the hospital, the patient had previously been treated at the unit physician, the patient was given paracetamol tablets and amoxicillin in the drink 3 times a day. but complaint of patients is not reduced and eventually the patient was taken to the emergency room with dustira unity.
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a. General complaint Fever Sleep Edema Icteric Thirst Appetite Weight : Present : Present : Absent : Present : Absent : Present : Absent

e. Stomach compliant Local pain Pain with pressure : Absent : Present

Pain in the entire stomach : Absent Pain associated with - Food - Defecation - Menstruation : : Absent : Absent : Absent

Sense of stomach tumor : Absent b. Head complaint Sight Nose Tongue : Absent : Absent : Absent Vomiting Diarrhea Obstipation Tenesmi ad ani Change in defecation Change in Urine : Absent : Absent : Absent : Absent : Absent : Absent

Swallow dysfunction : Absent Hearing Mouth Teeth Voice : Absent : Absent : Absent : Absent

Change in menstruation : Absent

c. Neck Complaint Suffocate in neck Gland enlargement Stiffness neck : Absent : Absent : Absent

f. Arm and Leg complaint Stiffness Fatigue Joint/muscle pain Numbness : Absent : Absent : Absent : Absent : Absent : Absent : Absent : Absent : Absent

d. Chest complaint Shortness of breath Chest pain Wheezing Cough Palpitate : Absent : Absent : Absent : Absent : Absent

Fractures Pain behind the knee Pain with pressure Wound/scar swollen

g. Other Complaint Skin Armpit Lymph node complaint : Absent : Absent : Absent

Additional History Taking a. Nutrition : Quality : Sufficient Quantity : Sufficient b. Contagious disease : Absent c. Hereditary disease : Absent d. Addiction e. Venereal disease : Absent : Absent

Endocrine gland complaint : - Menstruation - D.M - Thyroid - Others : : Absent : Absent : Absent

B. STATUS PRAESEN

I. GENERAL IMPRESSION a. General Awareness Character Impression illness Movement Sleep Height Weight : Composmentis : Cooperatif : Moderate : Unlimited : Supine with one pillow : 173 cm : 65 kg

Nutrition condition : BMI= 21,7 Skin nutrition Muscle nutrition Body shape Estimated age Skin : Sufficient : Sufficient : Athleticus : Appropriate : anemic (+), icteric (-)

b. Circulation Blood Pressure Pulse rate : Right :100/60 mmHg Left : 100/60 mmHg

: Right :72x/second, regular,equal, adequate Left :72x/second, regular,equal, adequate : 35,50C : Present : Absent

Body temperature Cold sweat Cyanosis

c. Respiratory condition Type Frequency Pattern : Abdominothoracal : 20x/ minute : Normal

Breath Smell Breath sound

: No abnormalities : No abnormalities

II. SPECIAL EXAMINATION a. Head 1. Skull Inspection Palpation : Symetric : No abnormalities

2. Face Inspection Palpation : Symetric, anemic (+), icteric (-) : No abnormalities

3. Eyes Location Eyelids Cornea Cornea reflex Pupils : Symetric : No abnormalities : No abnormalities : +/+ : Circle , Ishokor

Convergence Reaction : +/+ Sclera Conjunctiva Iris Movement Light Reaction Visus Funduskopi : Sub icteric : Anemic : No abnormalities : Normal to every direction : Direct+/+, Indirect +/+ : Examination is not conducted : Examination is not conducted

4. Ears Inspection Palpation Hearing : Symetric : No abnormalities : No abnormalities

5. Nose Inspection : No abnormalities

Obstruction Snot

: Absent : Absent

6. Lips Cyanosis Kheilitis Stomatitis angularis Rhagaden Perleche : Absent : Absent : Absent : Absent : Absent : Gums : No abnormalities 1 2 3 4 5 6 7 8 1 2 3 4 5 6 78 O = Caries

7. Teeth and Gums

8 7 6 5 4 3 2 1 8 7 6 5 4 3 2 1 X: Toothless 8. Tongue b. Neck 1. Inspection Trachea Glandula thyroid Size Shape Movement Surface Frenulum lingue

: Normal : No abnormalities : No abnormalities : anemic (-) : ikterik (-)

9. Mouth Cavity Hyperemic Lichen Aphtea Spots : Absent : Absent : Absent : Absent

10. Neck Cavity Mucous Membrane : No abnormalities : T1 T1 quite

Pharyng posterior wall : No hyperemic Tonsils

: Deviation not seen : Enlargement not seen

Venous expantion Neck venous pulsation Jugular venous pressure

: Absent : Absent : 5 + 1 cmH2O, not increase

2. Palpation Lymph nodes Glandula Thyroid Tumor Neck muscle Neck stiffness : No enlargement : No enlargement : Absent : No abnormalities : Absent

c. Axilla 1. Inspection Armpit hair Tumor : No abnormalities : Absent

2. Palpation Lymph nodes Tumor : No enlargement : Absent

d. Thorax Examination Anterior thorax 1. Inspection General shape Anteroposterior &Sagital Epigastric Angle Intercostals Space Movement Skin Musculatur Tumor Ictus cordis : Symetric : Anteroposterior < transversal : < 900 : Not widening nor narrowing : Symetric : anemic (+), icteric (-) : No abnormalities : Absent : Not seen

Other pulsation Venectation

: Absent : Absent

2. Palpation Skin Musculatur Mammae Intercostals Space Lung Movement Vocal fremitus : No abnormalities : No abnormalities : No abnormalities : Not widening nor narrowing Right : Symetric : Normal : : ICS V Linea midclavicularis sinistra : not bounding : not present : not present Left Symetric Normal

Ictus cordis Location Intensity Widening Thriil

3. Percussion Lung Percussion sound Liver lung border Right : Sonor Left Sonor

: ICS V Linea midclavicula dextra

Diafragmatic displacement : 1 intercostal space (2 cm)

Heart Up border Right Border Left Border : ICS II Linea sternalis sinistra : Linea sternalis dextra : ICS V linea midclavicularis sinistra

4. Auscultation Lung Main breath sound Right : Vesicular Left Vesicular

Additional breath sound : Ronkhi(-) Wheezing(-)

Ronkhi(-) Wheezing(-) Normal

Vocal resonance

: Normal

Heart Rhythm Main heart Sound : regular : M1 > M2, T1 > T2, Additional heart sound Obsteperous of heart Pericardial friction rub : Absent : Absent : Absent P1 < P2 A1 < A2, A2 > P2

Posterior Thorax 1. Inspection Shape Movement Skin Musculatur : Symetric : Symetric : ikterik (-) anemic (-) : No abnormalities Right Left

2. Palpation Intercostal space Musculatur Vocal fremitus

: Not widening nor narrowing : No abnormalities No abnormalities : Normal Normal

3. Percussion Lower border Diafragmatic displacement : Vertebra Th-X Vertebra Th-XI

: 1 intercostal space (2 cm)

4. Auscultation Main breath sound Additional breath sound : Vesicular : Rhonchi (-) Wheezing (-) Vocal resonance : Normal Vesicular Rhonchi (-) Wheezing (-) Normal

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e. Abdomen 1. Inspection Shape Abdomen muscle Skin Movement in breathing Intestines movement Pulsation Venectation : Flat : No abnormalities : icteric (-) : No abnormalities : Unseen : Absent : Absent

2. Palpation Abdomen Local palpation pressure Diffuse palpation pressure Detached pain Defance musculair Liver Enlargement Consitence Surface Edge Pain With Presure : Soft : present a/r hipokondrium dextra : Absent : Absent : Absent : Palpable : 3 cm BAC, 5 cm BPX : expansible : witness : sharp : present : Palpable : Schuffner I-II : soft : witness : difficult in value : absent : Not palpable : Not palpable Pain with pressure : -/-

Spleen Enlargement Consistence Surface Incisura Pain with pressure

Tumour/mass Ren

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3. Percussion Percussion sound Ascites Side dullness Shifting dullness Fluid wave : Tympany, dull ; Traube`s space (+) : : (-) : (-) : (-)

4. Auscultation Bowel sound Bruit Others : (+) Normal : Absent : No abnormalities : Knocking pain -/-

f. CVA(Costo vertebral angel) g. Groin 1. Inspection Tumor Lymph nodes Hernia

: Absent : Unseen enlargement : Absent

2. Palpassion Tumor Lymph node Hernia Pulsasi A. Femoralis : Absent : No enlargement : Absent : Palpable

3. Auscultation A. Femoralis : Examination is not conducted : Examination is not conducted : No abnormalities : Examination is not conducted Upper Lower

h. Genitalia i. Sacrum j. Anus& Rectum k. Extremities 1. Inspection Shape Movement

: No abnormalities No abnormalities : Unlimited Unimited

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Skin Muscle Edema Clubbing finger Palmar eritem

: No abnormalities No abnormalities : No abnormalities No abnormalities : Absent : Absent : Absent : : Absent : Absent : Absent : Present Absent Absent Absent Present Absent Absent Absent

2. Palpation Pain with pressure Tumour Edema (pitting/non pitting) Artery pulsation

l. Articulatio 1. Inspection Deformity Inflamation sign Others : No abnormalities : Absent : No abnormalities

2. Palpation Pain with pressure Fluctuation Others : Absent : Absent : No abnormalities

m. Neurologic Physiologic ReflexKPR Physiologic ReflexAPR Pathologic reflex Meningen reflex Sensoric : +/+ normal : +/+ normal : -/: absent : +/+

III. LABORATORY FINDINGS BLOOD Hemoglobin Leucocyte Erythrocyte : 8,5 g/dl : 5500 cell/mm3 : 3.500.000 cell/mm3

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Trombocyte Differential count Basophils Eosinophils Band Neutrophils

: 138.000 cell/mm3 : : 0 % : 1 % : 2 %

Segmented Neutrophils : 60 % Lymphocytes Monocytes : 25 % : 12 %

Erythrocyte Sedimentation Rate 1st hour 2nd hour : 30 mm : 65 mm

Blood Smears Erythrocyte : Hipochrom normosyter, DDR (+) P.falcifarum stadium trofozoit Leucocyte : No abnormalities

Groups of trombocyte : Deficient Impression : Anemia hipochromic ec malaria

URINE Color Muddiness Odor Density Reaction Albumin Reduction Urobilin Bilirubin : Yellow : Clear : Amoniak : 1.015 : Acid : : : : -

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Sediment Leucocyt Erythrocyte Crystal Bactery Epithelium : 5-8/ HPF : 6-9/HPF : : : 2-4/HPF

FAECES Colour Odor Consistency Mucus Blood Parasite Erithrocyt Leucocyt Worm Eggs Food remaining : Brown : Indol skatol : Slack : : : : : : : +

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RESUME

A man, 20 years old,occupation: army, single, came with complaint of fever. 9 days ago patient complained of a suddenly high fever. Fever complaint was preceded by rigoris then followed by caloris and sudoris after the fever get down. Fever complaint was accompanied by weakness, headache, nausea without vomiting and poor appetite. Fever complaint was accompanied by that looks yellow eyes and a face that looks pale. Fever complaint was not accompanied by a decrease in consciousness or convulsions. Fever complaint was not accompanied by decreasement of urination, change of urines color that get blackish. And complaint of defecation wasnt found. Fever complaint was not accompanied by severe pain in the calf or to make the patient unable to walk, bleeding in the eye, and do not live in flood zones. Fever complaint was not accompanied by a cough for more than three weeks, sweat out in the evenings or drastic weight loss. Fever complaints was not accompanied by rapid breathing and or shortness of breath in time.

Patients had been visiting and living in malaria endemic area in Papua, from 1 January to 15 April 2011 to carry out tamtama education. patients did not drink malaria prevention medication before going to the venue. While in Papua patients have never experienced such complaints. This is the first complaint that experienced by the patient, and family no one has suffered from this disease.

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Before the patient entered the hospital, the patient had previously been treated at the unit physician, the patient was given paracetamol tablets and amoxicillin in the drink 3 times a day. but complaint of patients is not reduced and eventually the patient was taken to the emergency room with dustira unity.

Further examination : a. General Awareness Impression illness Skin : Composmentis : Moderate : anemic (+), icteric (-)

b. Vital sign Blood Pressure Breathing Pulse rate Temperature Cyanosis Cold sweat : 100/60 mmHg : 20x/ second : 72x/second, regular,equal, adequate : 35,50C : Absent : Present

c. Special Examination Head Sclera Conjunctiva : Symetric : Sub icteric : Anemic

Thorax : Shape and movement are symmetric Skin Heart : anemic (+), icteric (-) : Heart border Normal 1st Heart Sound &2nd heart sound: reguler Lung : Vesikuler Right lung = Left Lung, Ronchi -/-, wheezing -/-

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Abdomen : Tympany, dull

Hepar

Palpable, 3 cm BAC 5 cm BPX

- Consitence expansible - Surface witness - Edge sharp - Pain With Presure present

Lien

: palpable, schuffner I-II Traubes space was filled - Consitence soft - Surface witness - Incisura difficult in value - Pain With Presure absent

Ren Ekstremity

: No palpable, Knocking pain -/-

: No abnormality

Laboratory Findings BLOOD :Erythrocyte sedimentation rate was high, leucopenia and trombocytopenia Erythrocyte Sedimentation Rate 1st hour 2nd hour : 30 mm : 65 mm : 5500 cell/mm3 : 3.500.000 cell/mm3 : 138.000 cell/mm3

Leucocyte Erythrocyte Trombocyte Blood Smears Erythrocyte

: Hipochrom Normosyter, DDR (+) P.falcifarum stadium trofozoit

Leucocyte

: No abnormalities

Groups of trombocyte : Deficient Impression : Anemia hipochromic ec malaria

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URINE FAECES

: Within normal limits : Within normal limits

IV. DIFFERENTIAL DIAGNOSIS Tropical Malaria Tertiana Malaria Typhoid fever with hepatitis Tifosa V. DIAGNOSIS Tropical Malaria

VI. EXAMINATION SUGGESTED : 1. DDR tests (repeated at the 3rd, 7th, 14th, 21th, and 28th day) 2. PfHRP2 and PfLDH test 3. AST, ALT, bilirubin total, bilirubin direct, bilirubin indirest test 4. Widal test I dan II, Gall Kulture

VII. TREATMENT IVFD Ringer Lactat maintenance 2L/24 hour Inj. Artem - 1st day 2x2 amp (160 mg) im - 2nd until 5th 2x1 amp (80 mg) im Dokxiciklin 2x100 mg (1 week) Kina tab 3x1 (1 week) Folic acid 1x1 PCT 3x500 mg Vitamin B complex 3x1 tab

VIII. PROGNOSE Quo ad vitam Quo ad functionam : Ad Bonam : Dubia Ad Bonam

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CASE DISCUSSION

Discussion of Chief Complaint patients come to rs dustira with chief complaint of fever I. fever of less than seven days include : Chikungunya, avian influenza, dengue fever II. fever for more than seven days include : Typhoid fever, malaria, leptospirosis, tbc, malignancy, hiv aids

Discussion of patients illness Fever complaint was preceded by shivering then followed by sweathing after the fever get down. The classic symptoms of malaria which is known as trias malaria are frigoris (shivering), calories (fever),sudoris (sweathing) that happen consecutively. Frigoris period (15-60 minutes) : begin to shiver, patient usually wrap his body with blanket. His body will vibrate until the teeth stumble to each other. then this period followed by calories period :characterized by red face, tachycardia, and the fever stays in few hours. After that patient will get into sudoris period: patient get sweathing a lot, the temperature goes down, and patient feel healthy.

Fever complaint was accompanied by severe headache without followed by unconsciousness decreasement and seizure. Complaint was accompanied with bodys weakness, appetite decreasement and pain at both of leg. Fever complaint was also accompanied by nausea but not until get throw up. The most happen prodormal sign of malaria tropika are headache, pain at the leg, cold feeling, nausea , vomitus and diarrhea but in this patient is not until vomitus and diarrhea copmplaint wasnt found. Fever complaint was accompanied by severe headache without followed by unconsciousness decreasement and seizure.

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To detect any possibility of cerebral malaria complication, such as consciousness decreasement thet stay more than 30 minutes and seizures attack. Fever complaint was not accompanied by decreasement of urination, change of urines color that get blackish. And complaint of defecation wasnt found. To detect any possibilities of kidney complications such as acute renal failure and black water fever. Fever complaint was not accompanied by swallow pain, cough and cold. To eliminate the possibility of fever caused by upper respiratory tractus infection Complaints body heat is not accompanied by cough more than 3 weeks, night sweats or weight loss drastically. To rule out the possibility of pulmonary tuberculosis in patients Fever complaint was not accompanied with pain at leg which hurt when it is pushed, yellow eyes, and bloody eyes. Patient hasnt visited any floody area in few months before. To eliminate fever caused by leptospirosis. Leptospirosis is characterized by pain at leg which hurt when it is pushed, yellow eyes, bloody eyes and patient has ever visited floody area before. Complaint of defecation wasnt found. In malaria sometimes we can find diarrhea. Patients had been visiting and living in malaria endemic area in Papua, from 1 January to 15 April 2011 to carry out tamtama education. patients did not drink malaria prevention medication before going to the venue History of traveling and staying in endemic malaria area support straighten of malarial diagnosis.

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Complaints like this the first time experienced by the patient, and family no one is suffering from a disease like this. To get rid of malaria disease recurrence in

Discussion of physical examination

1. General condition Patients awareness was compos mentis means patient absolutely awaken and gives an adequate respond to the stimulus that is given. This condition eliminates possibility of malaria cerebral. People with malaria cerebral usually come in apathy, somnolen until coma condition. Impression illness of this patient was moderate means patient has disturbtion in his activities and need peoples help to do his activities. 2. Vital signs : Temperature :35,5 C Patient with malaria usually comes with fever complaint thats why in his examination usually gives a febris temperature. But in this patient, there is an irregular temperature which is one of malaria tropikans characteristic. Blood pressure: 100/60 mmHg, right=left Patients blood pressure has a decreasement. Hypotension is a poorprognostic sign only when associated with poor perfusion, as evidenced by cool peripheries and poor capillary refill. Pulse : 72x/minutes, right = left, reguler, equal, adequate

Patients pulse is normal Respiration : 20 x/menit type thorakoabdominal

Patients respiration rate is normal. Respiration could be followed by pathologic sounds when there is a complication in the lung such as bronchitis or lobaric pneumonia.

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3. Special Examination a. Head i. Sclera ii. Conjunctiva : Sub icteric : Anemic

In some cases of malaria there could be complications. In malaria with liver dysfunction we can find jaundice and icteric at sclera. Severe jaundice is associated with P. falciparum infection is more common among adults than among children, and results from hemolysis, hepatocyte injury and cholestasis. In severe malaria, both infected and uninfected red cells show reduced deformabolity, which correlates with prognosis and development of anemia.

b. Neck i. Lymph nodes : No enlargement

ii. Jugular venous pressure: 5 + 1 cmH2O, not increase Usually any abnormalities is not found

c. Thoraks : Shape and movement are symmetric i. Cor : Heart sounds are pure regular

ii. Pulmo : VBS right = left Ronkhi - / - Wheezing - / Lung could be normal or found any abnormal sounds. d. Abdomen : flat and soft i. Hepar : palpable 3 cm BAC 5 cm BPX ii. Lien : palpable schuffner I-II, Traubes space was filled

Presence of hepatomegaly could be found in malaria. Spleenomegaly is a typical sign of malaria. The spleen get enlarge because there is accumulation of parasytes erythrocyte pigment.

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Discussion of laboratory examination a. Blood test Hb : acquired anemia Leukosit : within normal limits

Counts : found that decreased lymphocytes and monocytes increased thin smear morphology was found plasmodium vivax stage trofozoit b. Urine : within normal limit In general, if no complications then obtained from macroscopic examination of urine will get the normal, clear yellow color, the smell of ammonia, and acid reaction. c. Faeces : within normal limit

f. Blood smear: a. Erythrocyte : Hipochrom normocyt, DDR (+) P. Falcifarum stadium trofozoit b. Leucocyte : no abnormalities

c. Thrombocyte : deficient d. Impression : anemia hipochromic ec malaria

Sensitivity and specifity depend to a great extent on the experience of the microscopist, the quality of the slides, atands and microscope, and the time spent examining the slide. Artefacts are common and often confusing. Diagnosis: In this patient the differential diagnosis is to determine the etiology of primary or secondary Diagnosis Based on the history taking, physical examination and laboratory examination, can be concluded that patient suffer of tropical malaria.

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Things that support the diagnosis: History taking: - From history taking was found classic symptoms of malaria which is known as trias malaria are frigoris (shivering), calories (fever),sudoris (sweathing) that happen consecutively. - Prodormal sign of malaria tropika such as severe headache, pain at the leg, bodys weakness, nausea and appetite decreasement. - Patient has history of traveling and staying in endemic malaria area Physical examination: Hepatomegaly Skin and conjunctiva anemis Sclera yellow jaundice Traubes space was filled Spleenomegaly schuffner I-II is a typical sign of malaria. The spleen get enlarge because there is accumulation of parasytes erythrocyte pigment. Examination Suggested : 1. DDR tests (repeated at the 3rd, 7th, 14th, 21th, and 28th day To evaluate the effectivity of the teraphy and medication ressistancy. 2. PfHRP2 and PfLDH test PfHRP2 to detect plasmodium falciparum in a rapid way and PfLDH is to differ between the infection caused by p. falciparum or by p. vivax. The introduction of simple, rapid, sensitive, highly specific and increasingly affordable dipstick or card tests for the diagnosis of malaria has been a major advance in recent years 3. Total bilirubin and indirect bilirubin director test To assess the causes of jaundice in both eyes, whether prehepatik, heart or liver posts. 4. Widal test I dan II, Gall Kulture Untuk menghilangkan DD/ Demam Tifoi

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Treatment First line medication for tropical malaria with complication IVFD Ringer Lactat maintenance 2L/24 hour Inj. Artem - 1st day 2x2 amp (160 mg) im - 2nd until 5th 2x1 amp (80 mg) im Dokxiciklin 2x100 mg (1 week) Kina tab 3x1 (1 week) Folic acid 1x1 PCT 3x500 mg Vitamin B complex 3x1 tab

Prognose Quo ad vitam : ad bonam Because the patient can still do daily activities and this patient has good vital sign. Even patient had previous history of malaria but there was no complications found. Quo ad functionam : dubia ad bonam Quo ad functionam of this patient is dubia ad bonam because even patient was suffered by p. falciparum but there was accompanied complications found.

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LITERATURE REVIEW MALARIA THE PARASITE The malaria parasite is a mosquito-transmitted protozoan. Plasmodia are sporozoan parasites of red blood cells transmitted to animals (mammals, bird, reptiles) by the bites of mosquitoes. Protozoan parasites of the phylum Apicomplexa contain three genetic elements: the nuclear and mitochondrial genomes characteristic of virtually all eukaryotic cells and a 35-kilobase circular extra chromosomal DNA. This encodes a vestigial plastid (the apicoplast) that is an evolutionary homologue of the chloroplast of plants and algal cells. Four species of the genus Plasmodium infect humans, although infection with a fifth parasite P. knowlesi, a malaria of long-tailed and pig-tailed macaque monkeys, is an important cause of human malaria on the island of Burneo and peninsular Malaysia.. Almost all deaths and severe diseases are cause by P. falciparum. The three benigh malarias, P. vivax, P. ovale and P. malariae, all lie close together on the evolutionary tree near the other primate malarias. Severe disease with these species is relatively unusual, although on the island of New Guinea Plasmodium vivax is associated with significant mortality. Occasionally patients with vivax malaria will die from rupture of an enlarge spleen, and P. vivax infection in pregnancy reduce birth weight, which predisposes to neonatal death. GEOGRAPHICAL ASPECTS Distribution Malaria is endemic in 109 countries and is found throughout the tropics (Figure 73.1). In Africa, P. falciparum predominates, as it does in Papua New Guinea and Haiti, whereas P. vivax is more common in Central and parts of South America, North Africa, the Middle East and the Indian subcontinent. The prevalent of both species is approximately equal in other parts of South America, South-east Asia and Oceania. P. vivax is rare in sub-Saharan Africa (except for the horn of Africa), whereas P. ovale is common only in West Africa. P. malariae is found in most areas, but is relatively uncommon outside Africa. Malaria was once endemic in Europe and Northern Asia, and

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was introduced to North America, but it has been eradicated from these areas. In Northern China and North Korea. P.vivax strains (P. vivax hibernans) with long incubation periods and long intervals (10-12 months) between relapses may still be found.

EPIDEMIOLOGY The mosquito vector Malaria is transmitted by some species of anopheline mosquitoes. Malaria transmission does not occur at temperatures below 16 C, or above 33

C, and at

altitudes >2000m because development conditions for transmission are high humidity and an ambient temperature between 20 and 30 C. Although rainfall provides breeding sites for mosquitoes, excessive rainfall may wash away mosquito larvae and pupae.16 The epidemiology of malaria is complex and may vary considerably even within relatively small geographical areas.17-20 Intensities of malaria transmission vary from very low (on average one infectious bite per person every 10 years) to extremely high (three infectious bites per person per day). Malaria transmission to man depends on several interrelated factors. The most important pertain to the anopheline mosquito vector, and in particular is longevity. As sporogony (development of the sporozoite parasites in the vector) takes over a week (depending on ambient temperatures), the mosquito must survive for longer than this after feeding on a gametocyte-carrying human, if malaria is to be transmitted.

Clinical epidemiology Babies develop severe malaria relatively infrequently (although, if they do, the mortality is high). The factors responsible for this include passive transfer of maternal immunity,33 and the high hemoglobin F content of the infants erythrocytes which retards parasite development.34 In holoendemic areas the baby is inoculated repeatedly with sporozoites during the first year of life, but the blood stage infection is seldom severe.19

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people may receive up to three infectious bite per day. In this epidemiological context, the main clinical impact of falciparum malaria is to cause severe anemia in the 1-3-year ago group (figure 73.2). with less intense or more variable or unstable transmission the age range affected by severe malaria extends to older children, and cerebral malaria becomes a more prominent manifestation of severe diseases.35-37 although mortality falls with decreasing transmission intensity, it remains substantial until EIR falls well below one. In hyper endemic and holoendemic areas indigenous adults never develop severe malaria, unless they leave the transmission area and return years later (and even then malaria is seldom life-threatening). Immunity is constantly boosted and effective premonition prevents parasite burdens reaching dangerous levels. Most infections in adult are asymptomatic. Where transmission of malaria is low, erratic, markedly seasonal, or focal, symptomatic infections are more common. A state of premonition is often not attained. Symptomatic disease occurs at any age, and cerebral malaria is a prominent manifestation of severe diseases at all ages. This is termed unstable malaria. In many areas, the transmission of malaria varies considerably over short distances, and severe disease is common when non-immune individuals enter these areas (e.g. woodcutters in South America and South-east Asia where malaria is of the forest fringe type or highland refugees in Burundi descending into malarious low-land). Malaria is usually a rainy seasons disease coinciding with increased mosquito abundance. In some areas, parasite rates (i.e. the proportion of people with positive blood smears) are relatively constant throughout the year, but the majority of cases still do occur during the west season. In Europe, before eradication, falciparum malaria was common in spring and in late summer and autumn, and was termed aestivo-autumnal malaria. the intensity of transmission or endemicity can change.. Deforestation, population migration, and changes in agricultural practice have profound effects on malaria transmission. Urban malaria is becoming an increasing problem in many countries. In low transmission settings malaria can behave as an epidemic disease carrying a high mortality. Epidemics are caused by migration (i.e. introduction of susceptible hosts), the introduction of new vectors, or changes in the habits of the

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mosquito vector or the human host. Increasing international air travel and worsening antimalarial drug resistance have led to an increase in imported cases of malaria in tourists, travelers and immigrants. With the recent exception of some of the former Soviet republics in East Europe and West Asia, this has not led to the reintroduction of malaria to areas from where it had earlier been eradicated (although the vector, and thus the potential, remains). The incidence of malaria has risen markedly in several African countries, India, and Bangladesh over recent decades. Imported malaria is often misdiagnosed, leading to delays in treatment and severe presentations of falsiparum malaria are not uncommon. Malaria may also be transmitted by blood transfusion, transplantation, or through needle-sharing among intravenous drug addicts.

MALARIA PARASITE LIFE CYCLE Pre-erythrocytic development Infection with human malaria begins when the feeding female anopheline mosquito inoculates plasmodial sporozoites at the time of feeding.43The small motile sporozoites are injected during the phase of probing as the mosquitoes searches for a vascular space before aspirating blood. In most cases, relatively few sporozoites are injected (appromaxmately 8-15), but up to 100 may be introduced in some instance.4445

Most sporozoites come from the large salivary ducts and represent only a small

fraction of the total number in the salivary gland. After injection, they enter the circulation, either directly or via lymph channels (approximately 20%), and rapidly target the hepatic parenchymal cells. Within 45 min of the bite, all sporozoites have either entered the hepatocytes and there begins a phase of a sexual reproduction. This stage last on average between 5.5 (P. falciparum) and 15 days (P. malariae) before the hepatic schizont ruptures to release meroaoites into the bloodstream

Plosmodium

Prepatent period (days)

Incubation period (days)

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P.falciparum

11.0 (2.4)

13.1 (2.8)

P.vivax

12.2 (2.3)

13.4 (2.7)

P.malariae

32.7a

34.7a

P.ovale

12.0

14.1

Naturally acquaried infections are considered to have an incubation period of between 13 28 days

in some instances, the primary incubation period can be much longer. In P. vivax and P. ovale infections a proportions of the intrahepatic parasites do not develop, but instead rest inert as sleeping forms or hypnozoites, to awaken weeks or months later, and cause yhe relapses which of characterize infection whit these two species. During the pre-erytrhocytic or hepatic phase of development considerable asexual multiplication takes and many thousand of merozoites are released from aech ruptured infect hepatocyte. However, as only a few liver cells are infected, this phase is asymptomatic for the human host.

Asexual blood stage development

The metozoites liberated into the bloodstream closely resemble sporozoites. They are motile ovoid forms which invade red cells rapidly. The process of invasion involves attachment to the erythrocyte surface, orientation so that the apical complex (which protrudes slightly from one and of the merozoites and containts the rophtries, the micronemes, and dense granules) abuts the red cells, and then interiorization takes places by a wriggling boring motion inside a vacuole composed of the invaginated arytrhocyte, the parasite lies within the erythrocyte cytosol enveloped by its own plasma membrane and a surrounding parasiteophorous vacuolar membrane. The attachment of the merozoite to the red cells is mediated by the attachment of one or more of a family of erythrocyte binding proteins, localized to the micronemes of the merozoite apical

31

complex, to a specific erythrocyte rereceptor. In P.vivax this is related to the duffy blood group antigen Fya or Fyb.The absence of these phenotypes in west affrican, or people who originate from that region, explains their resistance to infection with P.falciparum the merozoite protein EBA 175, a product of the Duffy binding like (DBL) superfamilyof genes encoding ligands for hodt cell receptors, is clearly important.48,49 this bind to sialic acid and the peptide backbone of the red cell membrane sialoglycoprotein glycophorin A. But other, sialic acid dependent and independent pathways of invasion also occur indicating considerable reserver in the invasion system.48,50 Blinding is linked to activation of a parasite actin motor which provides the mechanical energy for the invasion process. The red cells surface receptor for P.malariae and P.ovale are not known.

During the early stage of intraerytrhocytic development (<12h), the small ring forms of the four pasite species appear similar under light microscopy. The young developing parasite looks like a signetring or , in yhe case of P.falciparum like a pair of stereo-headphones, with darkly staining chromatin in the nucleus, a circularrim of citoplasma, and a pale central food vacuole ( figures 73.3. 73.4). Parasite are freely motile within the erythrocyte. As they grow, they increase in size logarithmically and consume the erythrocyes contents (most of which is haemoglobin). With this increase in size, P.falciparum-infected erythrocytes become spherical and less deformable.51,52 Proteolysis of haemoglobin within the digestive vacuole of the growing parasites realeses for protein synthesis, but the liberated haem process a problem. When haem is freed from its protein scaffold, is oxidizesto the toxic ferric form. Intraparasitic toxicity is avoided by spontaneous dimerization to an inert crystalline substance, haemozoin. This may be facilitated nonenzymatically by parasite proteins. Non-polymerized haem exits the food vacuole but its then degraded in the cytosol by glutathione. Too much non-polymerizedhaem overwhealms the defence mechanism and toxic. The digested product, mainly the brown or black insolunle pigment haemozoin, can be readily seen within the digestive vacuole of the growing parasite. To abtain amino acids and other nutrients and to control the electrolytic milieu in the infected arythrocyte the parasite inserts specific transporters and other proteins in the red cell membrane.55

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At approximately 12 14 of development, P.falciparum parasites begin to exhibit a high molecular weight strain-specific varian antigen, plasmodium falciparum erythrocyte membrane protein 1 (PfEMP1) on the exterior surface of the infected red cell which mediates attachment of the infected erythrocyte to vascular endothelium.56,57 This is associated with knob-like projection from the erythrocyte membrane. Expression increases towards the middle of the cycle (24h). these knobby or K + red cells progressively disappear from the circulation by attachment or cytoadherence to the walls of venules and capillaries in the vital organs. This process is called sequestration. The other there benign human malarias do not cytoadhere in systemic blood vessels and all stages of development circulate in bloodstream.

As P.vivax grows it enlarges the infected red cell, which in contrast to P.falciparum, leads to an increase in deformability as the parasite matures. Red granules known as schuffners dots appear throughtout the erythrocyte. Similar dots are also prominent in P.ovale , which also distrost the shape of the infected erythrocyte (hence its name). P.malariae pruduces characteristic band forms as the parasite grows. It is usually present at low parasitaemias. When humans are infected with the potentially lethal monkey malaria p. Knowlestsi it also produces band forms, and is therefore often mistaken for P. malariae58. High parasitaemias (over 2%) are usually caused by P.falciparum22. Apporoximately nuclear division takes place to form a segmenter or schizont (the term meront is etymologically more correct). Eventually the growing parasite occupies the entire red cell which has become spherical, depleted in haemoglobin, and full of merozoites. It then ruptures, so that between 6 and 36 merozoites are realesed, destroying the remmants of the red cell. Following P.falciparum schizogony the residual cytoadherent erythrocyte membrane and associated malaria pigment often remain attached to the vascular endhotelium for many hours. The released merozoites rapidly re-invade other red cells and start a new asexual cycle. Thus, the infection expands logarithmically at approximately 10-fold per cycle.59 only a sub-population of erythrocytes can be invaded. This is determined largely by red cell age. P.vivax can invade red cells for up to 2 weeks after emergence from the bone marrow. In Thailand, P.falciparum parasites causing severe malaria showed unselective invasion, and had a graeter multiplication potential at high densities than those which

33

caused uncomplicated malaria.60,61 The asexual life cycle is apporoximately 24 h for P.knowlesi, 48 h for P.falciparum, P. vivax and P.ovale, and 72 h for P. Malariae

Sexual stages and development in the mostquito After a series of sexual cycle in plasmodium falciparum, a sub-populatioon of parasites develops into sexual forms (gamethocytes) which are long lived and motile. These are the stages which transmit in infection. The process of gametocytogony takes about 7- 10 datys in P. falciparum. Thus there is an interval of approximately 1 week between the peaks of asexual and sexual stage parasitaemia in acute falciparum

malaria. In contrast P. vivax begins gametocytogenesis immediately, and the process of gametocytogony in the blood srage infection takes only 4 days. Symptomatic P.vivax infection are tgerefore more likely to present whit patent gametocytaemia and to transmit before treatment then acute P.falciiparum infection. The male-to-female gametocyte sex ratio for P.falciparum is apporoximately 1:4.64 One male (containing 8 microgametes) and one female (macrogamete) are required per mosquito blood meal (apporoximately 2L) for infection to occur. Thus gametocyte densities of 1 per L theorerically sufficient to infect mostquitoes, a density beneath the limit of detection for most routine for microscopy. Following ingestion in the blood meal of a biting female anopheline mosquito, the male and female gametocytes become activated in the mosquitos gut. The male gametocytes undergo rapid nuclear division and each of the eight nuclei formed associates whit a flagellum (20-25 m long). The motile male microgametes separate and seek the female macrogametes. Fusion and meiosis then take place to form a zygote. For a brief period, the malaria parasite genome is diploid within 24 h the enlarging zygote becomes motile and this form (the ookinete) penetrates the wall of the mosquito mid-gut (stomach) where it encysts (as an oocyst). This spherical bag of parasites expands by asexsual division to reach diameter of approximately stage of oocyst development there is a characteristic pigment pattern and colour that allows specification (it was this that caught the eye of its discoverer, Ronald Ross, in 1894) , but these patterns become obscured by by the time the oocyst has matured to contain thousands of fusiform motile sporozoites. The oocyts finally bursts to liberate myriads of sporozoites into the coelomic cavity of mosquito. The sporozoites then migrate to the

34

salivary glands to await inoculation into the next human host during feeding. The development of the parasite in the mosquito is termed sporogony, and takes between 8 and 35 days depending on the ambient temperature and species of parasite and mosquito. The longevity of the mosquito is a critical factor in determining its vectorial capacity. (see above).

Molecular Genetics Inheritance in plasmodium is similar to that in other eukaryotes. Haploid and diploid generations alternate. A large number of individual genes were cloned and sequenced on the long and winding (and as yet unfinished) road towards the development of a malaria vaccine, and in the fast few years the entire genome of several a malaria parasites have been sequenced. P. falciparum has approximately 6000 genes in its 14 chromosomes and extrachromosomal elements compared with the 31.000 of its natural host. Codon composition is extremely biased to adenine and thymidine in P. falciparum but more evenly balanced in the other malaria parasites genomes. There appear to be some groupings of genes relared to function. For example, the genes encoding the merozoite surface proteins are grouped. The many genes encoding the variant red cell surface anrigens (var and rif families), which contribute to the antigenic diversity necessary for the parasite to elude the host immune system, are also located close to each other near the telomeres. The var gene product, the variant surface protein which mediates cytoadherence (PfEMP1) appears the main antigen determining the parasites population structure during chronic falciparum malaria infections.
64

Variation in surface antigenicity result from the activation of the different

var gene. This switching occurs at different rates, some of which exceed 2% per asexual cycle. It has been suggested that the diversity of these immunodominant variant repeat sequences interferes with the selection of high affinity antibody responses, and perpetuates low affinity responses in malaria. This confusion of the immune response delays the development of effective immunity.
65

immune selection also provides the

selective pressure to maintain diversity in T- and B cell epitopes through a high frequency of nonsynonymous base mutations during the asexual development of malaria parasites. On a large scale , drug resisrance has had a profound effect on the malaria parasite population structure. The progeny of single drug resistant parasites (

35

first bearing chloroquine resistence and later sulfadoxine pyrimethamine resistence) which otiginated in south-east asia have swept across India and then spread across southern and eastern Africa.

The mechanisms maintaining genetic diversity within the parasite genome are many and complex.66 some of the polymorphic antigens identified are encoded by single gene copies in the haploid genome. These polypeptide antigens are characterized by tandem repeat sequences. Unequal crossing over during recombination can generate completely different sequences of these repeats. As these repeat sequences are also antibody targets,their variation provides antigenic diversity.

PATHOPHYSIOLOGY

The pathophysiology of malaria results from destruction of erythrocytes, the liberation of parasite and erythrocyte material into the circulation, and the host reaction to these events. P. falciparum malaria infected erythrocytes sequester in the microcirculation of vital organs, interfering with microcirculatory flow and host tissue metabolism.

Toxicity and cytokines For many years malariologists hypothesized that parasites contained a toxin which was liberated at schizont rupture, and caused the symptoms of the paroxysm. No toxin in the strict sense of the word has ever been identified, but malaria parasites do induce release of cytokines in much the same way as bacterial endotoxin. 118,119 A glycolipid material with many of the proper-ties of bacterial endotoxin is released on meront rupture."' This material is associated with the glycosylphosphatidylinositol anchor which covalently links proteins including the malaria parasite surface antigens to the cell membrane lipid bilayer.120,
121

This activates host inflammatory responses in

macrophages by signal ling through toll-like receptor (TLR) 2 and to a lesser extent TLR 4,121,111 Malaria antigen-related IgE complexes also activate cytokine release. The limulus lysate assay, a test of endotoxin-like activity, is often positive in acute malaria. These products of malaria parasites, and the crude malaria pigment which is released at
36

schizont rupture, induce activation of the cytokine cascade in a similar manner to the endotoxin of bacteria. But they are consider ably less potent. For example an Lcoli bacteraernia of I bacterium/mL carries an approximate mortality of 20% whereas in falciparum malaria only parasite densities of well over 10'/mL produce such a lethal effect. Clearly, compared with bacteria, malaria parasites are notable for their lack of toxicity! Cells of the macrophage monocyte series, 7/5 T cells, (x/P T cells, CD14+ cells and endothelium are stimulated to release cytokines in a mutually amplifying chain reaction. Initially tumour necrosis factor (TNF), which plays a pivotal role, interleukin (IL)-I, and gamma interferon (TFN) are prodbred and these in turn induce release of a cascade of other 'pro-inflammatory' cytokines including IL-6, IL-8, IL-12, IL-18.121-127 These are balanced by production of the 'anti inflammatory' cytokines, notably IL-IO."' Cytokines are responsible for many of the symptoms and signs of the infection, particularly fever and malaise. Plasma concentrations of cytokines are elevated in both acute vivax and falcipanim malaria.121-111,129,130 In established vivax malaria, which tends to synchronize earlier than P, falciparum, a pulse release of TNF occurs at the time of schizont rupture and this is followed by the characteristic symptoms and signs of the 'paroxysm', i.e. shivering, cooll extremities, headache, chills, a spike of fever, and sometimes rigors followed by sweating, vasodilatation and defervescence."' For a given number of parasites Plasmodium vivax is a more potent inducer of TNF release than P. falciparum, which may explain its lower pyrogenic density. It has been proposed that severe malaria and bacterial septicaemia may have a common cytokine-mediated pathology, despite considerable differences in their clinical, metabolic and haemodynamic manifestations. Cytokine concentrations in the blood fluctuate widely over a short period of t; me, and are high in both P. tdwx and P. falciparum; indeed some of the highest TNF concentrations recorded in malaria occur during the paroxysms of synchronous P. Pit= infections."' Nearly all the TNF measured in these assays is bound to soluble receptors; there is usually little or no bioactivity. Nevertheless, in most series there is a positive correlation between cytokine levels and prognosis in severe falciparum malaria. Acute malaria is associated with high levels of most cytokines but the balance differs in relation to severity. IL- 12 and TGF-P I, which

37

may regulate the balance between pro-and antiinflammatory cytokines, are higher in uncomplicated than severe malaria. "I IL-12 is inversely correlated with plasma lactate a measure of disease severity IL-10, a potent antiinflammatory cytokine, increases markedly in severe malaria but, in fatal cases, does not increase sufficiently to restrain the production of TNE"' A reduced IL-I0/TNF ratio has also been associated with childhood malarial anaemia in areas of high transmission.""' All this points to a disturbed balance of cytokine production in severe malaria. The first studies to associate elevations in plasma cytokine levels with disease severity focused on TNF and cerebral malaria, and led to the suggestion that TNF played a causal role in coma and cerebral dysfunction. Genetic studies from Africa indicated that children with the (308A) TNF2 allele, a polymorphism in the TNF promoter region, had a relative risk of 7 for death or neurological sequelae from cerebral malaria .7' This finding was not confirmed in studies from South-east Asia. A separate polymorphism in this region which affects gene expression was associated with a four-fold increased risk of cerebral malaria." On the other hand, the clinical studies in cerebral malaria with anti-TNF antibodies, and other strategies to reduce TNF production reported to date have shown no convincing effects other than reduction in fever."' in contrast to contradictory evidence in severe falciparum malaria, there is good evidence that cytokines do play a causal role in the pathogenesis of cerebral symptoms in murine models of severe malaria."' Numerous interventions have been beneficial in this model, but the clinical relevance of these observations is uncertain as Murine 'cerebral malaria' is clinically and pathologically unlike human cerebral malaria. There is no direct evidence that systemic release of TNF or other cytokines causes coma in humans (although mechanisms involving local release of nitric oxide and other medicators within the central nervous system and consequent inhibition of neurotransmission can be hypothesized). In a large prospective study in adults with severe malaria, elevated plasma TNF concentrations were associated specifically with renal dysfunction,130 and TNF levels were actually lower in patients with pure cerebral malaria than those with other manifestations of severe disease. Severe malarial anaemia has been associated with yet another TNF promoter polymorphism (238A; odds ratio, OR 2,5).80 Taken together, these various finding do not support a cytokine mediated pathology that is common to sepsis and malaria, although they do suggest some role for

38

TNF and other cytokines in severe disease, (but not encephalopathy perse). The extent to which these cytokine abnormalities are a cause or an effect of severe disease remains to be determined. Cytokines are probably involved in placental dysfunction, suppression of erythropoiesis and inhibition of gluconeogenesis, and certainly do cause fever in malaria. Tolerance to malaria, or premunition, reflects both immune regulation of the infection and also reduced production of cytokines in response to mal toxic immunity). Cytokines upregulate the endothelial expression of vascular ligands for P. falciparum-infected erythrocytes, notably ICAM-1, and thus promote cytoadherence. They may also be important mediators of parasite killing by activating leukocytes, and possibly other cells, to release toxic oxygen sped oxide, and by generating parasiticidal lipid peroxides and causing fever. Thus, whereas high concentrations cytokines appear to be harmful, lower levels probably benefit the host.

Sequestration Erythrocytes containing mature forms of P. falciparum adhere to microvascular endothelium ('cytoadherence') and thus from the circulation, This process is known as sequestration (Figure 73.7). The simian malaria parasites P. coatneyi and P. fragile infecting rhesus monkeys also sequester, but this does not occur to a significant extent with the other three human malaria parasites. Sequestration is thought to be central to the pathophysiology of falciparum malaria.139-141 The mechanics of cytoadhefence are similar to leukocyte endothelial interactions. Tethering (the initial contact) is followed by rolling and then firm adherence (stasis). Once adherent, the parasitized cell remains stuck until schizogony and even aftewards the residual membranes (and often the attached pigment body) remain attached to the vascular endothelium. Rolling is probably the rate-limiting factor determining cytoadherence.142 Blood is a complex soup of deformable cells suspended in plasma proteins, electrolytes, and a variety of small organic molecules. its effective viscosity changes

39

non-linearly under the different shear rates encountered in the circulation (non-Newtonian behaviour). At haematocrits <12% (i.e. severe anaemia), red blood cell suspensions exhibit Newtonian behaviour. Under experimental conditions, changes in haematocrit over the range commonly encountered in severe malaria (venous haematocrit, 10-30%, capillary values are lower) have major effects on cytoadherence. Rolling increased five-fold as haematocrit rose from 10% to 20% and cytoadhesion rose 12-fold between 100/b and 30%. Over this range, the viscosity of blood approximately doubles, and so if shear stress is held constant, shear rates fall by approximately half allowing greater time for contact between cells and endothelium. The higher the haematocrit, the more that cells roll along the endothelial surface, and a higher proportion of these adhere to the vascular endothelium.143 Once infected red cells adhere, they do not enter the circulation again, remaining stuck until they rupture at merogony (schizogony).144

B Figure 73.7 Two electron micrographs (x4320) showing densely packed parasitized erythrocytes sequestered in cerebral venules of a fatal case of cerebral malaria. Note that even when no intracellular parasite is seen, electron dense deposits are evident on the cell membranes indicating the red cell does contain a parasite, but that its body has been missed in the section. The packing of red cells is much tighter than in normal conditions. (Courtesy of Emsrii Pongponratn.)

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Figure 73.8 Uninfected red cells must squeeze past the static, rigid, spherical cytoadherent parasitized erythrocytes to maintain flow. This is compromised by the reduced cleformability of uninfected red cells in severe malaria and the intererythrocytic adhesive forces that mediate rosetting.

Under febrile conditions cytoadherence begins at approximately 12 h after merozoite invasion, and reaches 50% of maximum after 14-16 h. Adherence is essentially complete in the second half of the parasites' 48-h asexual life cycle. As a consequence, whereas in the other malarias of man mature parasites are commonly seen on blood smears, these forms are rare in falciparum malaria, and often indicate serious infection." It was thought that ring stage-infected erythrocytes do not cytoadhere at all, but recent pathological and laboratory studies show that that they do, although much less so than more mature stages.144,145 Ring form-infected parasites are also concentrated in the spleen and placenta, raising the intriguing possibility that the entire asexual cycle could take place away from the peripheral circulation. Sequestration occurs predominantly in the venules of vital organs (Figure 73.7). It is not distributed uniformly throughout the body, being greatest in the brain, particularly the white matter, prominent in the heart, eyes, liver, kidneys, intestines and adipose tissue, and least in the skin.140,146 Even within the brain the distribution of sequestered erythrocytes varies markedly from vessel to vessel,144 possibly reflecting differences in the expression of endothelial receptors (Figure 73.8). Cytoadherence and the related phenomena of rosetting and autoagglutination lead to microcirculatory obstruction in falciparum malaria (Figure 73.7).147 The gross microcirculatory obstruction caused by cytoadherent erythrocytes has recently been clearly visualized in vivo using polarised light imaging (in the buccal

41

and rectal microcirculation) and by high resolution fluoroscein angiography of the retinal circulation.111,149 The consequences of microcirculatory obstruction are activation of the vascular endothelium, endothelial dysfunction, together with reduced oxygen and substrate supply, which leads to anaerobic glycolysis, lactic acidosis and cellular dysfunction.

Cytoadherence Cytoadherence is mediated by several different processes. The most important parasite ligands are a family of strain-specific, high molecular weight parasite-derived proteins termed P. falciparu?n erythrocyte membrane protein I or PfEMP-1.57,141,150 These variant surface antigen (VSA) proteins (molecular mass 240-20 kDa) are encoded by 'var' genes, a family of -60 genes distributed in three general locations within the haploid genome: either immediately adjacent to the telomere, close to a telomeric Ivaf gene, or in internal clusters.151 Each parasitized red cell expresses the product of a single gene, a process which is tightly controlled at the transcriptional level, and varies between different parasites and different PfEMP-1 genes.152 PfEMP-1 is transcribed, synthesized, and stored within the parasite. Beginning at around 12 h of development, it is then exported to the surface of the infecting erythrocyte.153 There it is apposed by an electrostatic interaction through the membrane to a submembranous accretion of parasite-derived knob-associated histicline-rich protein (KAHRP) which is in turn anchored to the red cell via the cytoskeleton protein ankryn."' These accretions cause humps or knobs on the surface of the red cell, which are the points of attachment to vascular endothelium (Figure 73.9). The protuberances are not essential for cytoadherence (Figure 73.10). A small subpopulation of naturally occurting parasites do not induce surface knobs, and parasites can be selected in culture which are knob negative (K-) but still cytoadhere. However, natural parasite isolates are nearly always knob positive (K+). PfEMP-1 protrudes from the red cell surface offering several Duffy binding-like (DBL) domains each capable of binding to particular vascular 'receptors' Analysis of multiple PfEMP-1 sequences has revealed common antigenic determinants in the DBL-1 domain, a

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constituent of the so-called 'head structure common to all PfEMP- I variants that is involved in the formation of rosettes and in cytoadherence. PfEMP- I expression is greatest in the middle of the asexual cycle. PfEMP1 is an important adhesion molecule and as it is a parasite protein exposed to immune recognition, it is also a major antigenic determinant for the blood stage parasite. Two other variant surface antigeps encoded by different gene families have been identified - the Rifins and the Surfins,155-156 Their function is uncertain. Proteins expressed only on the younger ring stage infected red cells have also been identified in parasite lines which subsequently develop a chondroitin-sulphate A binding phenotype. These could play a role in ring stage cytoadherence. As in other protozoal parasites, the immmodominant surface antigen undergoes antigenic variation to 'change its coat and avoid immune mediated attack. Each P. faiciparum var gene appears to have different rates of switching on and off, with a net result that the infecting parasite population 'switches, to a new variant of PfEMP I at an average rate of about 2% per asexual cycle in culture158 although this may be considerably higher in vivo. Interestingly, the PfEMP-1 gene expressed shows some dependence on previous variant expression, reflecting the effects of host immune response on parasite antigenic variation.159 In the chronic phase of untreated infections, this antigenic variation results in small waves of parasitaemia approximately every three weeks. In addition to the 'var', 'rifin and 'surfin variant surface antigen gene superfamilies of P. falciparum, genome sequencing has revealed the 'vir' gene superfamily in Plasmodium vivax.160 A protein similar to PfEMP-I named sequestrin (molecular mass 270 kDa) has been identified on the surface of infected red cells using anti-idiotypic antibodies raised against ont putative vascular receptors CD36 (see below).161 The protein MESA may also be partially expressed on the surface of the red cell and has been suggested as a contributor to cytoadherence. The central role of parasite derived proteins in cytoadherence is not accepted by all. It has been suggested that cytoadherence is mediated by altered red cell membrane components such as a modified form of the red cell cytoskeleton protein band 3 (the major erythrocyte anion transporter, also called Pfalhesiti).162 In culture, most parasites lose the ability to cytoadhere after several cycles of replication. In vivo,

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cytoadherence maybe modulated by the spleen.163 This has been shown in Saimiri monkeys infected with P.falciparum. Parasitized erythrocytes do not cytoadhere in s mized monkeys. Rare patients who have had a splenectodevelop falciparum malaria and in some of these all stages of the parasite are seen in peripheral blood smears.164

Vascular enclothelial ligands A number of different cell adhesion molecules expressed on the surface of vascular endothelium have been shown to bind parasitized red cells (Figure 73. 10). The interaction between these proteins and the variant surface adhesin of the parasitize red cell is complex. The property of cytoadherence can be studied in vitro with cells expressing the potential ligands on their surface (e.g. human umbilical vein/dermal microvascular or cerebral enclothelial cells or transfected COS cells) or with the immobilized purified candidate ligand proteins. Probably the most important of these proteins is the leukocyte differentiation antigen CD36 165,166;

Figure 73.10 Schematic representation of cytoadherence in falciparum malaria. On the red cell side, the principal ligand is the variant antigen pla5modium falciporum erythrocyte membrane protein I (PfEMPl). This is expressed on the surface of 'knobs' which protrude from the red cell surface. It is anchored beneath tolthe knob associated histicline rich protein (KAHRP), and stabilized by PfEMP3. The rifin and CLAG gene products are not directly involved in adhesion but CLAG does appear to be required for cytoadherence. Parasite modified band 3 (the major anion transporter) contributes to
44

adhesion probably by binding to thrombosponclin (TSA). Sequestrin is a distinct parasite derived protein also mediating adhesion. The ring stage adhesion"' (not shown) is distinct from NEW, and expressed in the first third of the asexual cycle. On the vascular endothelial side, many molecules facilitate adhesion by bir;ding PfEMPI. The most important is the cellular differentiation antigen: CD36. Intercellular adhesion molecule I (ICAM 1) is important particularly in the brain, elsewhere it synergises with CD36. Chondroitin sulphate A (CSA) attached to thrombomodulin (TM), are very important for placental sequestration. Hyaluronic acid (HA) has also been implicated as a receptor for placental sequestration, but the evidence for this has weakened as it has emerged that HA is usually contaminated with CSA. The other identified adhesion molecules are vascular cell adhesion molecule 1 (VCAMl), E-selectin, platelet enclothelial cell adhesion molecule I (PECAMI), m, P, integrin, heparan sulphate (HS) and P-selectin. Nearly all freshly obtained parasites bind to CD36.167 Binding is increased at low pH (<7.01 and in the presence of high calcium concentrations."' CD36 is constitutionally expressed on vascular endothelium, platelets, and monocytes/ macrophages but is usually not present on the surface of cerebral vessels,"' although it has been suggested that parasitized erythrocytes could bind via CD36 to platelets adherent to cerebral vascular endothelium." The intercellular adhesion molecule (ICAM-1 or CD54), which is also the receptor for rhinovirus attachment, appears to be the major cytoadherence receptor in the brain. 169,171 ICAM-1, but not CD36, is upregulated by cytokines (notably TNF(x), and provides a plausible pathological scenario whereby cytokine release enhances cytoadherence. At physiological shear rates (i.e. those likely to be encountered in the human microcirculation) the binding forces (c.10-"N) are similar for CD36 and ICAM-1.142,172,173 For both, the forces of attachment are lower than those required for detachment, which suggests post-attachment alterations to increase adhesion. Binding to the two ligands is synergistic. 174 Thrombospondin (a natural ligand for CD36) will also bind to some parasitized red cells (probably to modified band 3). Other proteins including VCAM-I, PECAM/CD31, E-selectin and the integrin alpha,-beta, have also been shown to bind in some circumstances.111 P-selectin has been shown to mediate

45

rolling. The relative importance of these molecules and their interactions in vivo is still not clear. Chondroitin sulphate A (CSA) appears to be the major receptor for cytoadherence in the placenta.175-177 Binding is mediated by a particular PfEMPI (var2CSA) which gives hope for a specific vaccine against malaria in pregriancy.178,179 Thus, the placenta selects a parasite subpopulation expressing this epitope. Antibodies which inhibit parasitized red cell cytoadherence by binding var2CSA are generally present in multigraviclae in endemic areas, but not primigravidae."' This probably explains why the adverse effects of pregnancy on birth weight are greater in primigravidae. Other as yet unidentified vascular receptors are also present, as sequestration also occuffs in vessels expressing none of the potential ligands identified so far. In summary ICAM-1 appears to be a major vascular ligand in the brain involved in cerebral sequestration, CSA is the major ligand in the placenta, and CD36 is probably the major ligand in the other organs. The relationship between cytoadherence, measured ex-vivo, and the severity of infection or clinical manifestations has been inconsistent between studies. This is not particularly surprising, as all parasitized erythrocytes cytoadhere. Severity is related to the number of parasites in the body and distribution of cytoadherence within the vital organs. The relative importance of parasite phenotype and the various potential vascular ligands in the pathophysiology of severe falciparum malaria and the precise role of the spleen as a modulator of cytoadherence still remains to be determined.

Rosetting Erythrocytes containing mature parasites also adhere to uninfected

erythrocytes.181 Ibis process leads to the formation of 'rosettes' when suspensions of parasitized erythrocytes are viewed under the microscope (Figure 73.11). Rosetting shares some characteristics of cytoadherence.182,183 it starts at around 16 h of asexual life cycle development (slightly after cytoadherence begins)184 and it is trypsin-sensitive. But parasite species which do not sequester do rosette"' and unlike cytoadherence,

46

rosetting is inhibited by certain heparin subfiactions and calcium-chelators. Furthermore, whereas all fresh isolates of P. falciparum cytoadhere, not all rosette. Rosetting is mediated by attachment of specific domains of PfEMP1 to the complement receptor CRI, heparan sulphate, blood group A antigen, and probably other red cell surface molecules. Attachment is facilitated by serum components recently identified as Complement factor D, albumin, and IgG anti-band 3 antibodies."' The forces required to separate a rosette are approximately five times greater than those required to separate cytoadherent cells, although shearing forces may still be effective in disrupting rosettes in vivo. When known rosetting parasite lines (K+R+) are perfused through the rat mesocaecum, an ex vivo model for the study of vascular perfusion, they cause significantly more microvascular obstruction than isolates which cytoadhere but do not rosette (K+R-)139,187 Rosetting has been associated with severe malaria in some studies but not in others.188-191 it has been suggested that rosetting might enwurage cytoadherence by reducing flow (shear rate), which would enhance anaerobic glycolysis, reduce pH and facilitate adherence of infected erythrocytes to venular endothelium. Rosetting tends to ' start in venules, and this could certainly reduce flow. The adhesive forces involved in rosetting could impede forward flow of uninfected erythrocytes as they squeeze past sticky cytoadherent parasitized red cells in cap illaries and venules (Figure 73.9).192,193 The mechanical obstruction or 'static hindrance' would be compounded by the lack of deformability of the adherent, and circulating parasitized red cells.

Aggregation Recently a new adherence property of parasitized red cells has been characterized, and associated with disease severity.194,195 This is the platelet mediated aggregation of parasitized erythrocytes and is mediated via platelet CD36. These cells clump together in ex vivo cultures. Aggregation could also contribute to vascular occlusion.

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Red cell deformability As Plasmodium vivax matures inside the erythrocyte, the cell enlarges and becomes more deformable." Plasmodium falciparum does exactly the opposite; the normally flexible biconcave disc becomes progressively more spherical and rigid.","' The reduction in deformability results from reduced membrane fluidiM increasing sphericity, and the enlarging and relatively rigid intraerythrocytic parasite. Infected red cells are less filterable than uninfected cells, and readily removed by the spleen. indeed it has been argued that sequestration is an adaptive response to escape

B Figure 73.11 Rosetting. (A) Uninfected red bl9od cells bind to a P. vivax-infected erythrocyte. (Courtesy of R. Udomsangpetch.)N Transmission electron micrograph of a rosette around a P. falciparuminfected erythrocyte. (Courtesy of D. Ferguson.) splenic filtration. However, reduced deformability alone cannot account for microvascular obstruction as it would lead to obstruction at the mid-capillary (i.e. the smallest internal diameter in the vasculature) and could not explain sequestration in venules.193 Even in severe malaria the majority of red cells are still unifected. A reduction of uninfected red cell deformabifity hal been recognized as a major contributor to disease severrity and outcome. This phenomenon is specific to severe falciparum malaria; it is not found in sepsis.147 Increased erythrocyte rigidity measu low shear stresses encountered in capillaries and venules is corelated closely with outcome in severe malaria.193,196 When assessed at the higher shear rates encountered on the arterial side, and importantly in the spleen, reduced red cell deformability correlates with anaernia.197
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SIGNS AND SYMPTOMS Symptoms of malaria include fever, shivering, arthralgia (joint pain), vomiting, anemia (caused by hemolysis), hemoglobinuria, retinal damage, and convulsions. The classic symptom of malaria is cyclical occurrence of sudden coldness followed by rigor and then fever and sweating lasting four to six hours, occurring every two days in P. vivax and P. ovale infections, while every three days for P. Malariae, P. falciparum can have recurrent fever every 3648 hours or a less pronounced and almost continuous fever. For reasons that are poorly understood, but that may be related to high intracranial pressure, children with malaria frequently exhibit abnormal posturing, a sign indicating severe brain damage. Malaria has been found to cause cognitive impairments, especially in children. It causes widespread anemia during a period of rapid brain development and also direct brain damage. This neurologic damage results from cerebral malaria to which children are more vulnerable. Cerebral malaria is associated with retinal whitening, which may be a useful clinical sign in distinguishing malaria from other causes of fever. Severe malaria is almost exclusively caused by P. falciparum infection, and usually arises 614 days after infection.[18] Consequences of severe malaria include coma and death if untreatedyoung children and pregnant women are especially vulnerable. Splenomegaly (enlarged spleen), severe headache, cerebral ischemia, hepatomegaly (enlarged liver), hypoglycemia, and hemoglobinuria with renal failure may occur. Renal failure is a feature of blackwater fever, where hemoglobin from lysed red blood cells leaks into the urine. Severe malaria can progress extremely rapidly and cause death within hours or days.[18] In the most severe cases of the disease, fatality rates can exceed 20%, even with intensive care and treatment.[19] In endemic areas, treatment is often less satisfactory and the overall fatality rate for all cases of malaria can be as high as one in ten.[20] Over the longer term, developmental impairments have been documented in children who have suffered episodes of severe malaria

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Main symptoms of malaria

EXAMINATION In addition to a physical examination and the assessment of health history, the following tests are instrumental for accurate diagnosis: Laboratory findings Normochromic, normocytic anemia is usually documented. The leucocyte count is generally low to normal, although it maybe raised in very severe onfections. The erythrocyte sedimentation rate, degree of plasma viscosity, and level of C-reactive protein are high. The platelet count is usually reduced to ~105 /L. severe infections maybe accompanied by prolonged prothrombin and partial thromboplastin times and by severe thrombocytopenia. Levels of antithrombin III are reduced even in mild infection. In uncomplicated malaria, plasma concentration of electrolytes, blood urea nitrogen, and creatinine are usually normal. Findings in severe malaria may include metabolic acidosis, with low plasma concentration of glucose, sodium, bicarbonate, calcium, phosphate, and albumin together with elevation on lactate, blood urea nitrogen, creatinine, urate, muscle and liver enzymes, and conjugated and unconjugated bilirubin. Hypergammaglobinemia is usual in immune amd semi immune sunjects, and urinalysis usually gives normal results. In adults and children with cerebral malaria, the mean
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opening pressure at lumbar puncture is 160 mm of CSF but because the normal range in children is lower (<100 mm) most values in children are elevated.; the CSF is usually normal or has a slightly elevated total protein level [<1.0 g/L (100 mg/dL)] and cell count (<20/L). The CSF lactate concentration is reaised in cerebral malaria, and the glucose maybe slightly low relative to blood.

Diagnosis Malaria is dignosed by microscopic examination of the blood. It is not a clinical diagnosis. In malaria endemic areas where malaria is the most common cause of fever, then it is reasonable to treat for malaria if rapid test or microscopy are not readily available. Blood Smears Thick and thin blood film are made on clean, grease free glass slides. The thick film is approximately 30 times more sensitive than the thin film, although sensitivity and specifity depend to a great extent on the experience of the microscopist, the quality of the slides, atands and microscope, and the time spent examining the slide. Artefacts are common and often confusing. Speciation of malaria at the trophozoite stage is easier on the thin film, although gametocytes and schizonts are more likely to be seen on the thick film. The thin film is more accurate for parasite counting. The number of parasitized red cells per 1000 red cells should be counted. Of there are two parasites in one red cell, this is counted as one. At low parasitemias (<5/10000 on the thin folm) the thick film should be counted; the number of parasites per 200, or preferably 500 white cells is noted. These figures can then be corrected by the total red cell and white cell counts to give the number of parasites per unit blood volume (L). Of the white count is not available then the count is assumed to be 8000 L. an alternative os to count all parasites in fixed volume of blood. In severe malaria parasotemias are usually high, and the stage of parasite development should be assessed on the film. The proportion of asexual parasites containing visible pigment (i.e. mature trophozyte and schizonts) should be counted. The presence of pigment in neutrophils and monocyte should also be noted and counted. In patient who have already received antimalarial treatment, pigment may still be present in

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leukocytes after clearance of parasitemia, and this is an important clue to the diagnosis. Monocytes containinbg pigment are cleared more slowly than pigment containing neutrophils. Rapid Diagnostic Test The introduction of simple, rapid, sensitive, highly specific and increasingly affordable dipstick or card tests for the diagnosis of malaria has been a major advance in recent years. These are based on antibody detection of malaria specific antigens in blood samples; currently histidine rich protein 2 (PfHRP2), parasite lactate dehydogenase (which is antigenically distinct from the host enzyme), and adolase. Current PfHRP2 and PfLDH tests, based on color reactions, provide a diagnostic sensitivity for

plasmodium falciparum similar to train microscopists.. COMPLICATION OF MALARIA DISEASE World Health Organisation (WHO) had defined severe malaria while it is found

Plasmodium falciparum in asexual form with one or some of complication below: 1990 WHO definition of severe malaria 1. Cerebral malaria unrousable coma not attributable to any other cause in a patient with falciparum malaria. The coma should persist for at least 30 min (I h in the 2000 definition) after a generalized convulsion to make the distinction from transient postictal coma. Coma should be assessed using Blantyre coma scale in children of the Glasgow coma scale in adults. 2. Severe anaemia normocytic anaemia with haematocrit <15% or haemoglobin <5 g/dL in the presence of parasitaemia more tha 10.000/L. note that finger prick samples may underestimate the heaemolobn concentration by up to 1 g if the finger is squeezed, if anaemia is hypochromic and/or microcytic, iron deficiency and thalassaemia/haemoglobinopathy must be exclude. (These criteria are rather generous; and would include many children in high transmission areas. Aparasitaemia of >100000/ L might be a more appropriate threshold.) 3. Renal failure defined as a urine output of<400 mL 24 h in adults, or 12 mL/kg in 24 h in children, failing to improve after rehydration, and a serum creatinine of more

52

than 256 mol/L (>3.0 mg/dL). (In practice for initial assessment, the serum creatinine alone is used.) 4. Pulmonary oedemaor adult respiratory distress syndrome. 5. Hypocaemia defined as a whole blood glucose concentration of less tha 2.2 mmol.L (40mg/dL). 6. Circulatory collapse or shock hypotension (syntolic blood pressu<50 mmHgin children aged 1-5 years or <70 mmHg in adult), with cold clammy skin or core skin temperature difference > 10 C. (The more recent review declined to give precise definitions, but noted the lack of sensitivity or specificity of core-peripheral measurements.) Capillary refill time is not mentioned but recent studies indicate this simple test provides a good assessment of severity.449 7. Spotaneous bleeding from gums, nose, gas \trointestinal tract, etc. and /or substantial laboratory evidence of DIC. (This is relatively unusual.) 8. Reoeated generalized convulsions more than two observed within 24 h despite 24 cooling. (In young children, these may be febrile convulsions, and the other clinical and parasitological features need to be taken into account.) Clinical evidence of seizure activity may be subtle (e.g. tonic clonic eye movenments, profuse salivation, delayed coma recovery). 9. Acidaemia defined as an arterial or capillary pH <7.35 (note temperature corrections are needed as most patient are hotter than 37 C) or acidosis defined as a plasma bicarbonate concertration <15 mol/L or a base excess >10. (Operationally. The clinical presentation of respiratory distress or acidotic breathing is focused upon in the 2000 recommendations. Abnormal breathing patterns are a sign of severity indicating severe acidosis, pulmonary oedema or pneumonia.) 10. Macroscopic haemoglobinuria if definitely associated with acute malaria infection and not merely the result of oxidant anti malarial drugs in patiens with erythrocyte enzyme defects such as G6Pd\D deficiency. (This is difficult to ascertain in practice: if the G6PD deficiency. y\this part of the definition is not very useful.) 11. Postmortem confirmation of diagnosis. In fatal cases a diagnosis of severe falciparum malaria can be confirmed by histogicalexamination of a postmortem needle necroscopy of the brain. The characteristic features. Found especially grey matter, are venules/capillaries packed with erythrocyte containing mature

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trophozoites and schizonts of P. faciparum. (these features may not be presents who die several days after the tart of treatment, although there is usually some residual pigment in the cerebral vessels.) 12. Impairment of consciousness less marked than unrousable coma. (Any impairment of consciousness must be treated seriously. Assessment using the Glasgow Coma Scale is straightforward, but the Blantyre Scale needs careful local standartdization particularly in younger children.) 13. Prostration: Inability to sit unassisted in a child who is normally able to do so. In a child not old enough to sit. This is defined as an inability to feed. This definition is based on examination not history. 14. Hyperparasitaemia the relation of parasitaemia to severity of illness different in different populations and age groups. But in general very high parasite densities are associated with increased risk of severe disease, e.g. >4% parasitaemia is dangerous in non-immunes. But may be well tolerated in semi immune children. In nonimmune children studied in Thailand a parasitaemia 4% carried a 3% mortality (30 tim higher than in all uncomplicated malaria) but in areas of high transmission value mush higher may be tolerated well. Many use a threshould definition of 10% parasitaemia n higher transmission settings. The following were not considered criteria of severe malaria: Jaundice detected clinically or defined by a serum bilirubin concentration >50 mol/L (3.0 mg/dL). This only marker of severe malaria when combined with evidence of other vital organ dysfunction such as coma or renal failure. Hyperpyrexia a rectal temperature above 40 C in adults and children is no longer considered a sigh of severity.

TREATMENT

Antimalarial medication Antimalarial medications are designed to prevent or cure malaria. Drugs which are used for prophylaxis, treatment & in the prevention for malaria are called antimalarials.

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Treatment of malaria in individuals with suspected or confirmed

infection

Prevention of infection in individuals visiting a malaria-endemic region

who Have no immunity (prophylaxys).

Routine Intermittent treatment of certain groups in endemic regions.

Current practice in treating cases of malaria is based around the concept of combination therapy, since this offers several advantages - reduced risk of treatment failure, reduced risk of developing resistance, enhanced convenience and reduced sideeffects. It is practical to consider antimalarials by chemical structure since this is associated with important properties of each drug, such as mechanism of action. Prompt parasitological confirmation by microscopy or alternatively by RDTs is recommended in all patients suspected of malaria before treatment is started.[1] Treatment solely on the basis of clinical suspicion should only be considered when a parasitological diagnosis is not accessible

Medications
Quinine and related agents

Quinine has a long history stretching from Peru, and the discovery of the cinchona tree, and the potential uses of its bark, to the current day and a collection of derivatives that are still frequently used in the prevention and treatment of malaria. Quinine is an alkaloid that acts as a blood schizonticidal and weak gametocide against Plasmodium vivax and Plasmodium malariae. As an alkaloid, it is accumulated in the food vacuoles of Plasmodium species, especially Plasmodium falciparum. It acts by inhibiting the hemozoin biocrystallization, thus facilitating an aggregation of cytotoxic heme. Quinine is less effective and more toxic as a blood schizonticidal agent than chloroquine; however, it is still very effective and widely used in the treatment of acute cases of severe P. falciparum. It is especially useful in areas where there is known to be a high level of resistance to chloroquine, mefloquine, and sulfa drug combinations with pyrimethamine. Quinine is also used in post-exposure treatment of individuals returning from an area where malaria is endemic.

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The treatment regimen of quinine is complex and is determined largely by the parasite's level of resistance and the reason for drug therapy (i.e. acute treatment or prophylaxis). The World Health Organization recommendation for quinine is 20 mg/kg first times and 10 mg/kg 8 hr for 5days where parasites are sensitive to quinine, combined with doxycycline, tetracycline or clindamycin. Doses can be given by oral, intravenous or intramuscular routes. The recommended method depends on the urgency of treatment and the available resources (i.e. sterilised needles for IV or IM injections). Use of quinine is characterised by a frequently experienced syndrome called cinchonism. Tinnitus (a hearing impairment), rashes, vertigo, nausea, vomiting and abdominal pain are the most common symptoms. Neurological effects are experienced in some cases due to the drug's neurotoxic properties. These actions are mediated through the interactions of Quinine causing a decrease in the excitability of the motor neuron end plates. This often results in functional impairment of the eighth cranial nerve, resulting in confusion, delirium and coma. Quinine can cause hypoglycaemia through its action of stimulating insulin secretion; this occurs in therapeutic doses and therefore it is advised that glucose levels are monitored in all patients every 46 hours. This effect can be exaggerated in pregnancy and therefore additional care in administering and monitoring the dosage is essential. Repeated or over-dosage can result in renal failure and death through depression of the respiratory system. Quinimax and quinidine are the two most commonly used alkaloids related to quinine in the treatment or prevention of malaria. Quinimax is a combination of four alkaloids (quinine, quinidine, cinchoine and cinchonidine). This combination has been shown in several studies to be more effective than quinine, supposedly due to a synergistic action between the four cinchona derivatives. Quinidine is a direct derivative of quinine. It is a distereoisomer, thus having similar anti-malarial properties to the parent compound. Quinidine is recommended only for the treatment of severe cases of malaria.
Chloroquine

Chloroquine was until recently the most widely used anti-malarial. It was the original prototype from which most methods of treatment are derived. It is also the least expensive, best tested and safest of all available drugs. The emergence of drug-resistant

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parasitic strains is rapidly decreasing its effectiveness; however, it is still the first-line drug of choice in most sub-Saharan African countries. It is now suggested that it is used in combination with other antimalarial drugs to extend its effective usage. Chloroquine is a 4-aminoquinolone compound with a complicated and still unclear mechanism of action. It is believed to reach high concentrations in the vacuoles of the parasite, which, due to its alkaline nature, raises the internal pH. It controls the conversion of toxic heme to hemozoin by inhibiting the biocrystallization of hemozoin, thus poisoning the parasite through excess levels of toxicity. Other potential mechanisms through which it may act include interfering with the biosynthesis of parasitic nucleic acids and the formation of a chloroquine-haem or chloroquine-DNA complex. The most significant level of activity found is against all forms of the schizonts (with the obvious exception of chloroquine-resistant P. falciparum and P. vivax strains) and the gametocytes of P. vivax, P. malariae, P. ovale as well as the immature gametocytes of P. falciparum. Chloroquine also has a significant anti-pyretic and anti-inflammatory effect when used to treat P. vivax infections, and thus it may still remain useful even when resistance is more widespread. Children and adults should receive 25 mg of chloroquine per kg given over 3 days. A pharmacokinetically superior regime, recommended by the WHO, involves giving an initial dose of 10 mg/kg followed 68 hours later by 5 mg/kg, then 5 mg/kg on the following 2 days. For chemoprophylaxis: 5 mg/kg/week (single dose) or 10 mg/kg/week divided into 6 daily doses is advised. Chloroquine is only recommended as a prophylactic drug in regions only affected by P. vivax and sensitive P. falciparum strains. Chloroquine has been used in the treatment of malaria for many years and no abortifacient or teratogenic effects have been reported during this time; therefore, it is considered very safe to use during pregnancy. However, itching can occur at intolerable level and Chloroquinine can be a provocation factor of psoriasis.
Amodiaquine

Amodiaquine is a 4-aminoquinolone anti-malarial drug similar in structure and mechanism of action to chloroquine. Amodiaquine has tended to be administered in areas of chloroquine resistance while some patients prefer its tendency to cause less itching than chloroquine. Amodiaquine is now available in a combined formulation with

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artesunate (ASAQ) and is among the artemisinin-combination therapies recommended by the World Health Organisation. Combination with sulfadoxine=pyrimethamine is no longer recommended (WHO guidelines 2010). The drug should be given in doses between 25 mg/kg and 35 mg/kg over 3 days in a similar method to that used in chloroquine administration. Adverse reactions are generally similar in severity and type to that seen in chloroquine treatment. In addition, bradycardia, itching, nausea, vomiting and some abdominal pain have been recorded. Some blood and hepatic disorders have also been seen in a small number of patients.
Pyrimethamine

Pyrimethamine is used in the treatment of uncomplicated malaria. It is particularly useful in cases of chloroquine-resistant P. falciparum strains when combined with sulfadoxine. It acts by inhibiting dihydrofolate reductase in the parasite thus preventing the biosynthesis of purines and pyrimidines, thereby halting the processes of DNA synthesis, cell division and reproduction. It acts primarily on the schizonts during the erythrocytic phase, and nowadays is only used in concert with a sulfonamide.
Proguanil

Proguanil (chloroguanide) is a biguanide; a synthetic derivative of pyrimidine. It was developed in 1945 by a British Antimalarial research group. It has many mechanisms of action but primarily is mediated through conversion to the active metabolite cycloguanil pamoate. This inhibits the malarial dihydrofolate reductase enzyme. Its most prominent effect is on the primary tissue stages of P. falciparum, P. vivax and P. ovale. It has no known effect against hypnozoites therefore is not used in the prevention of relapse. It has a weak blood schizonticidal activity and is not recommended for therapy of acute infection. However it is useful in prophylaxis when combined with atovaquone or chloroquine (in areas where there is no chloroquine resistance). 3 mg/kg is the advised dosage per day, (hence approximate adult dosage is 200 mg). The pharmacokinetic profile of the drugs indicates that a half dose, twice daily maintains the plasma levels with a greater level of consistency, thus giving a greater level of protection. The proguanil- chloroquine combination does not provide effective protection against resistant strains of P. falciparum. There are very few side effects to

58

proguanil, with slight hair loss and mouth ulcers being occasionally reported following prophylactic use.
Sulfonamides

Sulfadoxine and sulfamethoxypyridazine are specific inhibitors of the enzyme dihydropteroate synthetase in the tetrahydrofolate synthesis pathway of malaria parasites. They are structural analogs of p-aminobenzoic acid (PABA) and compete with PABA to block its conversion to dihydrofolic acid. Sulfonamides act on the schizont stages of the erythrocytic (asexual) cycle. When administered alone sulfonamides are not efficacious in treating malaria but co-administration with the antifolate pyrimethamine, most commonly as fixed-dose sulfadoxine-pyrimethamine (Fansidar), produces synergistic effects sufficient to cure sensitive strains of malaria. Sulfonamides are not recommended for chemoprophylaxis because of rare but severe skin reactions experienced. However it is used frequently for clinical episodes of the disease.
Mefloquine

Mefloquine was developed during the Vietnam War and is chemically related to quinine. It was developed to protect American troops against multi-drug resistant P. falciparum. It is a very potent blood schizonticide with a long half-life. It is thought to act by forming toxic heme complexes that damage parasitic food vacuoles. It is now used solely for the prevention of resistant strains of P. falciparum despite being effective against P. vivax, P. ovale and P. marlariae. Mefloquine is effective in prophylaxis and for acute therapy. It is now strictly used for resistant strains (and is usually combined with Artesunate). Chloroquine/proguanil or sufha drug-

pyrimethamine combinations should be used in all other Plasmodia infections. A dose of 1525 mg/kg is recommended, depending on the prevalence of mefloquine resistance. The increased dosage is associated with a much greater level of intolerance, most noticeably in young children; with the drug inducing vomiting and oesophagitis. The effects during pregnancy are unknown, although it has been linked with an increased number of stillbirths. It is not recommended for use during the first trimester, although considered safe during the second and third trimesters. Mefloquine frequently produces side effects, including nausea, vomiting, diarrhea, abdominal pain
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and dizziness. Several associations with neurological events have been made, namely affective and anxiety disorders, hallucinations, sleep disturbances, psychosis, toxic encephalopathy, convulsions and delirium. Cardiovascular effects have been recorded with bradycardia and sinus arrhythmia being consistently recorded in 68% of patients treated with mefloquine (in one hospital-based study). Mefloquine can only be taken for a period up to 6 months due to side effects. After this, other drugs (such as those based on paludrine/nivaquine) again need to be taken.
Atovaquone

Atovaquone is only available in combination with proguanil under the name Malarone, albeit at a price higher than Lariam. It is commonly used in prophylaxis by travellers and used to treat falciparum malaria in developed countries.
Primaquine

Primaquine is a highly active 8-aminoquinolone that is used in treating all types of malaria infection. It is most effective against gametocytes but also acts on hypnozoites, blood schizonticytes and the dormant plasmodia in P. vivax and P. ovale. It is the only known drug to cure both relapsing malaria infections and acute cases. The mechanism of action is not fully understood but it is thought to block oxidative metabolism in Plasmodia. For the prevention of relapse in P. vivax and P. ovale 0.15 mg/kg should be given for 14 days. As a gametocytocidal drug in P. falciparum infections a single dose of 0.75 mg/kg repeated 7 days later is sufficient. This treatment method is only used in conjunction with another effective blood schizonticidal drug. There are few significant side effects although it has been shown that primaquine may cause anorexia, nausea, vomiting, cramps, chest weakness, anaemia, some suppression of myeloid activity and abdominal pains. In cases of over-dosage granulocytopenia may occur.
Artemisinin and derivatives

Artemisinin is a Chinese herb (qinghaosu) that has been used in the treatment of fevers for over 1,000 years,[4] thus predating the use of Quinine in the western world. It is derived from the plant Artemisia annua, with the first documentation as a successful
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therapeutic agent in the treatment of malaria is in 340 AD by Ge Hong in his book Zhou Hou Bei Ji Fang (A Handbook of Prescriptions for Emergencies).[5] Ge Hong extracted the artemesinin using a simple macerate, and this method is still in use today.[6] The active compound was isolated first in 1971 and named artemsinin. It is a sesquiterpene lactone with a chemically rare peroxide bridge linkage. It is this that is thought to be responsible for the majority of its anti-malarial action, although the target within the parasite remains controversial. At present it is strictly controlled under WHO guidelines as it has proven to be effective against all forms of multi-drug resistant P. falciparum, thus every care is taken to ensure compliance and adherence together with other behaviors associated with the development of resistance. It is also only given in combination with other anti-malarials.

Artemisinin has a very rapid action and the vast majority of acute

patients treated show significant improvement within 13 days of receiving treatment. It has demonstrated the fastest clearance of all anti-malarials currently used and acts primarily on the trophozite phase, thus preventing progression of the disease. Semisynthetic artemisinin derivatives (e.g. artesunate, artemether) are easier to use than the parent compound and are converted rapidly once in the body to the active compound dihydroartemesinin. On the first day of treatment 20 mg/kg should be given, this dose is then reduced to 10 mg/kg per day for the 6 following days. Few side effects are associated with artemesinin use. However, headaches, nausea, vomiting, abnormal bleeding, dark urine, itching and some drug fever have been reported by a small number of patients. Some cardiac changes were reported during a clinical trial, notably non specific ST changes and a first degree atrioventricular block (these disappeared when the patients recovered from the malarial fever).

Artemether is a methyl ether derivative of dihydroartemesinin. It is

similar to artemesinin in mode of action but demonstrates a reduced ability as a hypnozoiticidal compound, instead acting more significantly to decrease gametocyte carriage. Similar restrictions are in place, as with artemesinin, to prevent the development of resistance, therefore it is only used in combination therapy for severe acute cases of drug-resistant P. falciparum. It should be administered in a 7 day course with 4 mg/kg given per day for 3 days, followed by 1.6 mg/kg for 3 days. Side effects of the drug are few but include potential neurotoxicity developing if high doses are given.

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Artesunate is a hemisuccinate derivative of the active metabolite

dihydroartemisin. Currently it is the most frequently used of all the artemesinin-type drugs. Its only effect is mediated through a reduction in the gametocyte transmission. It is used in combination therapy and is effective in cases of uncomplicated P. falciparum. The dosage recommended by the WHO is a 5 or 7 day course (depending on the predicted adherence level) of 4 mg/kg for 3 days (usually given in combination with mefloquine) followed by 2 mg/kg for the remaining 2 or 4 days. In large studies carried out on over 10,000 patients in Thailand no adverse effects have been shown.

Dihydroartemisinin is the active metabolite to which artemesinin is

reduced. It is the most effective artemesinin compound and the least stable. It has a strong blood schizonticidal action and reduces gametocyte transmission. It is used for therapeutic treatment of cases of resistant and uncomplicated P. falciparum. 4 mg/kg doses are recommended on the first day of therapy followed by 2 mg/kg for 6 days. As with artesunate, no side effects to treatment have thus far been recorded.

Arteether is an ethyl ether derivative of dihydroartemisinin. It is used in

combination therapy for cases of uncomplicated resistant P. falciparum. The recommended dosage is 150 mg/kg per day for 3 days given by IM injections. With the exception of a small number of cases demonstrating neurotoxicity following parenteral administration no side effects have been recorded.
Halofantrine

Halofantrine is a relatively new drug developed by the Walter Reed Army Institute of Research in the 1960s. It is a phenanthrene methanol, chemically related to Quinine and acts acting as a blood schizonticide effective against all plasmodium parasites. Its mechanism of action is similar to other anti-malarials. Cytotoxic complexes are formed with ferritoporphyrin XI that cause plasmodial membrane damage. Despite being effective against drug resistant parasites, halofantrine is not commonly used in the treatment (prophylactic or therapeutic) of malaria due to its high cost. It has very variable bioavailability and has been shown to have potentially high levels of cardiotoxicity. It is still a useful drug and can be used in patients that are known to be free of heart disease and are suffering from severe and resistant forms of acute malaria. A popular drug based on halofantrine is Halfan. The level of

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governmental control and the prescription-only basis on which it can be used contributes to the cost, thus halofantrine is not frequently used. A dose of 8 mg/kg of halofantrine is advised to be given in three doses at six hour intervals for the duration of the clinical episode. It is not recommended for children under 10 kg despite data supporting the use and demonstrating that it is well tolerated. The most frequently experienced side-effects include nausea, abdominal pain, diarrhea, and itch. Severe ventricular dysrhythmias, occasionally causing death are seen when high doses are administered. This is due to prolongation of the QTc interval. Halofantrine is not recommended for use in pregnancy and lactation, in small children, or in patients that have taken mefloquine previously. Lumefantrine is a relative of halofantrine that is used in some combination antimalarial regimens.[7]
Doxycycline

Probably one of the more prevalent antimalarial drugs prescribed, due to its relative effectiveness and cheapness, doxycycline is a tetracycline compound derived from oxytetracycline. The tetracyclines were one of the earliest groups of antibiotics to be developed and are still used widely in many types of infection. It is a bacteriostatic agent that acts to inhibit the process of protein synthesis by binding to the 30S ribosomal subunit thus preventing the 50s and 30s units from bonding. Doxycycline is used primarily for chemoprophylaxis in areas where chloroquine resistance exists. It can also be used in combination with quinine to treat resistant cases of P. falciparum but has a very slow action in acute malaria, and should not be used as monotherapy. When treating acute cases and given in combination with quinine; 100 mg of doxycycline should be given per day for 7 days. In prophylactic therapy, 100 mg (adult dose) of doxycycline should be given every day during exposure to malaria. The most commonly experienced side effects are permanent enamel hypoplasia, transient depression of bone growth, gastrointestinal disturbances and some increased levels of photosensitivity. Due to its effect of bone and tooth growth it is not used in children under 8, pregnant or lactating women and those with a known hepatic dysfunction. Tetracycline is only used in combination for the treatment of acute cases of P. falciparum infections. This is due to its slow onset. Unlike doxycycline it is not used in chemoprophylaxis. For tetracycline, 250 mg is the recommended adult dosage (it should

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not be used in children) for 5 or 7 days depending on the level of adherence and compliance expected. Oesophageal ulceration, gastrointestinal upset and interferences with the process of ossification and depression of bone growth are known to occur. The majority of side effects associated with doxycycline are also experienced.
Clindamycin

Clindamycin is a derivative of lincomycin, with a slow action against blood schizonticides. It is only used in combination with quinine in the treatment of acute cases of resistant P. falciparum infections and not as a prophylactic. Being more expensive and toxic than the other antibiotic alternatives, it is used only in cases where the Tetracyclines are contraindicated (for example in children). Clindamycin should be given in conjunction with quinine as a 300 mg dose (in adults) four times a day for 5 days. The only side effects recorded in patients taking clindamycin are nausea, vomiting and abdominal pains and cramps. However these can be alleviated by consuming large quantities of water and food when taking the drug. Pseudomembranous colitis (caused by Clostridium difficile) has also developed in some patients; this condition may be fatal in a small number of cases.

Resistance Antimalarial resistance is common.[8] Anti-malarial drug resistance has been defined as: "the ability of a parasite to survive and/or multiply despite the administration and absorption of a drug given in doses equal to or higher than those usually recommended but within tolerance of the subject. The drug in question must gain access to the parasite or the infected red blood cell for the duration of the time necessary for its normal action." In most instances this refers to parasites that remaining following on from an observed treatment. Thus excluding all cases where anti-malarial prophylaxis has failed. In order for a case to be defined as resistant, the patient under question must have received a known and observed anti-malarial therapy whilst the blood drug and metabolite concentrations are monitored concurrently. The techniques used to demonstrate this are: in vivo, in vitro, animal model testing and the most recently developed molecular techniques.

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Drug resistant parasites are often used to explain malaria treatment failure. However, they are two potentially very different clinical scenarios. The failure to clear parasitemia and recover from an acute clinical episode when a suitable treatment has been given and anti-malarial resistance in its true form. Drug resistance may lead to treatment failure, but treatment failure is not necessarily caused by drug resistance despite assisting with its development. A multitude of factors can be involved in the processes including problems with non-compliance and adherence, poor drug quality, interactions with other pharmaceuticals, poor absorption, misdiagnosis and incorrect doses being given. The majority of these factors also contribute to the development of drug resistance. The generation of resistance can be complicated and varies between plasmodium species. It is generally accepted to be initiated primarily through a spontaneous mutation that provides some evolutionary benefit, thus giving an anti-malarial used a reduced level of sensitivity. This can be caused by a single point mutation or multiple mutations. In most instances a mutation will be fatal for the parasite or the drug pressure will remove parasites that remain susceptible, however some resistant parasites will survive. Resistance can become firmly established within a parasite population, existing for long periods of time. The first type of resistance to be acknowledged was to chloroquine in Thailand in 1957. The biological mechanism behind this resistance was subsequently discovered to be related to the development of an efflux mechanism that expels chloroquine from the parasite before the level required to effectively inhibit the process of haem polymerization (that is necessary to prevent build up of the toxic by products formed by haemoglobin digestion). This theory has been supported by evidence showing that resistance can be effectively reversed on the addition of substances which halt the efflux. The resistance of other quinolone anti-malarials such as amiodiaquine, mefloquine, halofantrine and quinine are thought to have occurred by similar mechanisms. Plasmodium have developed resistance against antifolate combination drugs, the most commonly used being sulfadoxine and pyrimethamine. Two gene mutations are thought to be responsible, allowing synergistic blockages of two enzymes involved in

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folate synthesis. Regional variations of specific mutations give differing levels of resistance. Atovaquone is recommended to be used only in combination with another antimalarial compound as the selection of resistant parasites occurs very quickly when used in mono-therapy. Resistance is thought to originate from a single-point mutation in the gene coding for cytochrome-b.
Spread of resistance

There is no single factor that confers the greatest degree of influence on the spread of drug resistance, but a number of plausible causes associated with an increase have been acknowledged. These include aspects of economics, human behaviour, pharmokinetics, and the biology of vectors and parasites. The most influential causes are examined below: 1. The biological influences are based on the parasites ability to survive the

presence of an anti-malarial thus enabling the persistence of resistance and the potential for further transmission despite treatment. In normal circumstances any parasites that persist after treatment are destroyed by the host's immune system, therefore any factors that act to reduce the elimination of parasites could facilitate the development of resistance. This attempts to explain the poorer response associated with

immunocompromised individuals, pregnant women and young children. 2. There has been evidence to suggest that certain parasite-vector

combinations can alternatively enhance or inhibit the transmission of resistant parasites, causing 'pocket-like' areas of resistance. 3. The use of anti-malarials developed from similar basic chemical

compounds can increase the rate of resistance development, for example crossresistance to chloroquine and amiodiaquine, two 4-aminoquinolones and mefloquine conferring resistance to quinine and halofantrine. This phenomenon may reduce the usefulness of newly developed therapies prior to large-scale usage. 4. The resistance to anti-malarials may be increased by a process found in

some species of plasmodium, where a degree of phenotypic plasticity was exhibited, allowing the rapid development of resistance to a new drug, even if the drug has not been previously experienced.

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5.

The pharmokinetics of the chosen anti-malarial are key; the decision of

choosing a long-half life over a drug that is metabolised quickly is complex and still remains unclear. Drugs with shorter half-life's require more frequent administration to maintain the correct plasma concentrations, therefore potentially presenting more problems if levels of adherence and compliance are unreliable, but longer-lasting drugs can increase the development of resistance due to prolonged periods of low drug concentration. 6. The pharmokinetics of anti-malarials is important when using

combination therapy. Mismatched drug combinations, for example having an 'unprotected' period where one drug dominates can seriously increase the likelihood of selection for resistant parasites. 7. Ecologically there is a linkage between the level of transmission and the

development of resistance, however at present this still remains unclear. 8. The treatment regime prescribed can have a substantial influence on the

development of resistance. This can involve the drug intake, combination and interactions as well as the drug's pharmokinetic and dynamic properties.
PREVENTION

The prevention of anti-malarial drug resistance is of enormous public health importance. It can be assumed that no therapy currently under development or to be developed in the foreseeable future will be totally protective against malaria. In accordance with this, there is the possibility of resistance developing to any given therapy that is developed. This is a serious concern, as the rate at which new drugs are produced by no means matches the rate of the development of resistance. In addition, the most newly developed therapeutics tend to be the most expensive and are required in the largest quantities by some of the poorest areas of the world. Therefore it is apparent that the degree to which malaria can be controlled depends on the careful use of the current drugs to limit, insofar as it is possible, any further development of resistance. Provisions essential to this process include the delivery of fast primary care where staff are well trained and supported with the necessary supplies for efficient treatment. This in itself is inadequate in large areas where malaria is endemic thus presenting an initial problem. One method proposed that aims to avoid the fundamental

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lack in certain countries health care infrastructure is the privatisation of some areas, thus enabling drugs to be purchased on the open market from sources that are not officially related to the health care industry. Although this is now gaining some support there are many problems related to limited access and improper drug use, which could potentially increase the rate of resistance development to an even greater extent. There are two general approaches to preventing the spread of resistance: preventing malaria infections and, preventing the transmission of resistant parasites. Preventing malaria infections developing has a substantial effect on the potential rate of development of resistance, by directly reducing the number of cases of malaria thus decreasing the requirement for anti-malarial therapy. Preventing the transmission of resistant parasites limits the risk of resistant malarial infections becoming endemic and can be controlled by a variety of non-medical methods including insecticide-treated bed nets, indoor residual spraying, environmental controls (such as swamp draining) and personal protective methods such as using mosquito repellent. Chemoprophylaxis is also important in the transmission of malaria infection and resistance in defined populations (for example travellers). A hope for future of anti-malarial therapy is the development of an effective malaria vaccine. This could have enormous public health benefits, providing a costeffective and easily applicable approach to preventing not only the onset of malaria but the transmission of gametocytes, thus reducing the risk of resistance developing. Antimalarial therapy could be also be diversified by combining a potentially effective vaccine with current chemotherapy, thereby reducing the chance of vaccine resistance developing.

COMBINATION TERAPHY The problem of the development of malaria resistance must be weighed against the essential goal of anti-malarial care; that is to reduce morbidity and mortality. Thus a balance must be reached that attempts to achieve both goals whilst not compromising either too much by doing so. The most successful attempts so far have been in the administration of combination therapy. This can be defined as, 'the simultaneous use of two or more blood schizonticidal drugs with independent modes of action and different biochemical targets in the parasite'. There is much evidence to support the use of

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combination therapies, some of which has been discussed previously, however several problems prevent the wide use in the areas where its use is most advisable. These include: problems identifying the most suitable drug for different epidemiological situations, the expense of combined therapy (it is over 10 times more expensive than traditional mono-therapy), how soon the programmes should be introduced and problems linked with policy implementation and issues of compliance. The combinations of drugs currently prescribed can be divided into two categories: non-artemesinin-based combinations and artemesinin based combinations. It is also important to distinguish fixed-dose combination therapies (in which two or more drugs are co-formulated into a single tablet) from combinations achieved by taking two separate antimalarials.

Non-artemisinin based combinations

Components

Description This fixed-dose combination has been used for many years, causes few adverse effects, is cheap and effective in a single dose, thus

Dose

Sulfadoxinepyrimethamine(SP) (Fansidar)

decreasing problems associated with adherence and compliance. In technical terms Fansidar is not generally considered a true combination therapy since the components do not possess independent curative activity.[1] Fansidar should no longer be used alone for treatment of falciparum malaria. High levels of resistance to one or both

25 mg/kg of sulfadoxine and 1.25 mg/kg of pyrimethamine.

Chloroquine 25 mg/kg over 3 days with a single dose of SP as described above. 10 mg/kg of Amodiaquine per day for 3 days with a single standard dose of SP.

SP plus chloroquine

components means this combination is effective in few locations and it is no longer recommended by WHO guidelines.
[1]

This combination has been shown to produce a faster rate of clinical recovery than SP SP plus amodiaquine and chloroquine, but is clearly inferior to artemisinin-based combinations (ACTs) for the treatment of malaria.[1] SP plus mefloquine (Fansimef) This single dose pill offered obvious advantages of convenience over more complex

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regimes but it has not been recommended for use for many years owing to widespread resistance to the components. This combination retains a high cure rate in many areas. Problems with this regime include the relatively complicated drug regimen, where quinine must be taken every 8 hours for 7 days. Quinine plus tetracycline/doxycycline Additionally, there are significant side effects with quinine ('cinchonism') and tetracyclines are contraindicated in children and pregnant women (these groups should use clindamycin instead). With the advent of artemisinin-combination therapies, quinine-based treatment is less popular than previously. Quinine 10 mg/kg doses every 8 hours and tetracycline in 4 mg/kg doses every 6 hours for 7 days.

According to WHO guidelines 2010, artemisinin-based combination therapies should be used in preference to amodiaquine plus sulfadoxine-pyrimethamine for the treatment of uncomplicated P. falciparum malaria.

Artemisinin-based combination therapies (ACTs)

Artemesinin has a very different mode of action than conventional anti-malarials (see information above), this makes is particularly useful in the treatment of resistant infections, however in order to prevent the development of resistance to this drug it is only recommended in combination with another non-artemesinin based therapy. It produces a very rapid reduction in the parasite biomass with an associated reduction in clinical symptoms and is known to cause a reduction in the transmission of gametocytes thus decreasing the potential for the spread of resistant alleles. At present there is no known resistance to Artemesinin (though some resistant strains may be emerging)[9] and very few reported side-effects to drug usage, however this data is limited.

Components Artesunate and amodiaquine (Coarsucam and ASAQ)

Description This combination has been tested and proved to be efficacious in many areas where amodiaquine retains some efficacy. A

Dose Dosage is as a fixed-dose combination (ASAQ) recommended

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potential disadvantage is a suggested link with neutropenia. It's recommended by the WHO for uncomplicated falciparum malaria.
[1]

as 4 mg/kg of Artesunate and 10 mg/kg of Amodiaquine per day for 3 days.

This has been used as an efficacious first-line treatment regimen in areas of Thailand for many years. Mefloquine is known to cause vomiting in children and induces some neuropsychiatric and cardiotoxic effects, interestingly these Artesunate and mefloquine (Artequin and ASMQ) adverse reactions seem to be reduced when the drug is combined with artesunate, it is suggested that this is due to a delayed onset of action of mefloquine. This is not considered a viable option to be introduced in Africa due to the long half-life of mefloquine, which potentially could exert a high selection pressure on parasites. It's recommended by the WHO for uncomplicated falciparum malaria.[1] This combination has been extensively tested in 16 clinical trials, proving effective in children under 5 and has been shown to be better tolerated than artesunate plus mefloquine combinations. Artemether and lumefantrine (Coartem Riamet, Amatem and Lonart) There are no serious side effects documented but the drug is not recommended in pregnant or lactating women due to limited safety testing in these groups. This is the most viable option for widespread use and is available in fixed-dose formulas thus increasing compliance and adherence. It's recommended by the WHO for uncomplicated falciparum malaria.[1] Artesunate and sulfadoxine/pyrimethamine This is a well tolerated combination but the overall level of efficacy still depends It is recommended in doses The standard dose required is 4 mg/kg per day of Artesunate plus 25 mg/kg of Mefloquine as a split dose of 15 mg/kg on day 2 and 10 mg/kg on day three.

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(Ariplus and Amalar plus)

on the level of resistance to sulfadoxine and pyrimethamine thus limiting is usage. It is recommended by the WHO for uncomplicated falciparum malaria.
[1]

of 4 mg/kg of Artesunate per day for 3 days and a single dose of 25 mg/kg of SP.

Has been studied mainly in China, Vietnam and other countries in SEAsia. The Dihydroartemisininpiperaquine (Duo-Cotecxin, Artekin) drug has been shown to be highly efficacious (greater than 90%). It's recommended by the WHO for uncomplicated falciparum malaria.

Manufactured by Shin Poong Pharmaceutical. Has been tested and demonstrated a clinical response rate of Pyronaridine and artesunate (Pyramax) 100% in one trial in Hainan (an area with high levels of P. falciparum resistance to Pyronaridine). A multi-centre phase III trial conducted in Africa found a 99.5% response rate.[10]

Other combinations Several other anti-malarial combinations have been used or are in development. For example, Chlorproguanil-dapsone and artesunate (CDA) appears efficacious but the problem of haemolysis in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency is likely to prevent widespread use.

PROGNOSTIC FACTORS The prognostic factors listed in the table below Biochemistry Hypoglicaemia Hyperlactatemia Acidosis <2,2 mmol/L >5 mmol/L Arterial pH <7,3 Venous plasma HCO3 <15 mmol/L Serum creatinine >265 mol/L

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Total bilirubin Liver enzymes

>50 mol/L SGOT (AST) >3 upper limit of normal SGPT (ALT) >3 upper limit of normal 5-Nucleatidase CPK Myoglobin

Muscle enzymes

Urate Haematology Leucocytosis

>600 mol/L

>12000/L Severe anemia (PCV < 15 %)

Coagulopathy

Platelets <50000/L Prothrombin time prolonged >3 s Prolonged partial Thromboplastin time Fibrinogen: <200 mg/dL

Parasitology Hyperparasitaemia >100000/L increased mortality >500000/L high mortality >20 % of parasites are pigment-contaonong thropozytes and schizonts >5 % of neutrophils contain visible malaria pigment

The table reflect vital organ dysfunction and magnitude of the parasite burden. They are not absolute and in fatal case, several factors usually co-exist. Some of the apparently poor prognostic factors can have a benign explanation. Hyperventilation (respiratory distress) is usually a bad sign (indicating metabolic acidosis, pulmonary oedema, or pneumonia), but shallow tachipneu can result from high fever alone (the tidal volume is lower). Upper gastrointestinal bleeding in cerebral malaria may also occur spontaneously. The prognostic implocations of severe anemia depend on the rate whoch haematocrit falls, the co-existing parasitemia and metabolic abnormalities and the stage of the infection. If anemia develops gradually then even haemaglobin values less thab 7 gr/dL (packed cell volume <20 %) can be surprisingly well tolerated as there is time for homeostatic adaptation such as the right shift in the oxygen dissociation

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curve, the increase in cardiac index and the fall in systemic vascular resistence. Hypotension is a poorprognostic sign only when associated with poor perfusion, as evidenced by cool peripheries and poor capillary refill. Patients particularly children, with acute malaria often have very low blood pressures but they are warm and well perfused. The concentration of lactate in venous or arterial blood or CSF is linearly proportional to the severity of disease. In terms of predictive prognostic values, the admission venous bicarbonate concentration has the best sensitivity and specifity, and it is available widely. Persistent acidosis with low plasma bicarbonate and elevated plasma lactate 4 hours after admission indicates a poor prognosis.Although a deep jaundice is often a bad sign, some adults patients develop a profound cholestatic jaundice without other evidence of vital organ dysfunction. Parasitemia has traditionally been used as a measure of severity. The sensivity and specificity of parasitemia alone is limited, but can be improved by staging parasite development (more mature parasites worse prognosis) and counting the number of polymorphonuclear neutrophil leucocytes which contain pigment (>5 % - poorer prognosis). For any parasitemia the prognosis is worse if >20 % of parasites contain visible pigment and better if >50 % of parasites

are at the tiny ring stage. Recent studies indicate that measurement of plasmodium falciparum Histidine Rich protein 2 (PfHRP2) in plasma or serum can be used to estimate the sequestered parasite biomass in severe malaria.

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BIBLIOGRAPHY

Fauci, A.S., Kasper, D.L., Longo, D.L., Braunwald, E., Hauser, S.L., Jameson, J.L., et al. 2008. Acute Viral Hepatitis. In: Powers , A.C., Ed. Harrisons Principal of Internal Medicine. 17th ed. New York Chicago San Fransisco Lisbon London Madrid Mexico City New Delhi San Juan Seoul Singapore Sydney Toronto: Mc-Graw Hill Company Inc. 19321948.Mcphee, J Stephen., Hammer D Garry.,et all : Renal disease .

Pathophysiology of Disease: An Introduction to Clinical Medicine, Sixth Edition. 2010 Sudoyo, Aru W.et all.BUKU AJAR ILMU PENYAKIT DALAMjilid III., edisi IV. Jakarta : Pusat penerbitan Departemen ilmu penyakit dalam Fakultas kedokteran Universitas Indonesia, 2006. Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia (PAPDI), Konsensus Penanganan Malaria 2003, Agustus 2003. Manson.2009. Tropical disease. Philadelphia : Elsevier Incorporation. 22th edition.

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CASE RESPONSE TROPICAL MALARIAE

Oleh:

Arief Fakhrizal
NIM. 41101125

Reported to : Kol (P). Eddy Harjadi S. dr.SpPD NRP 29886

INTERNAL MEDICINE DEPARTEMENT DUSTIRA HOSPITAL / MEDICAL FACULTY OF GENERAL ACHMAD YANI UNIVERSITY CIMAHI 2011

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