Malaria

Malaria is a protozoan disease transmitted by the bite of

infected Anopheles mosquitoes.
Most important of the parasitic diseases of humans, with
transmission in 103 countries affecting more than 1 billion
people and causing between 1 and 3 million deaths each year
Four (or 5 ?) species of the genus Plasmodium cause nearly
all malarial infections in humans : P. falciparum, P. vivax, P.
ovale, and P. malariae (the 5th is P. knowlesi)
Almost all deaths are caused by falciparum malaria.

CLINICAL FEATURES

Clinical symptoms include the following: Fatigue,

Malaise, Shaking chills, Arthralgia, Myalgia, Paroxysm of
fever, shaking chills, and sweats
The classic paroxysm begins with a period of shivering
and chills, which lasts for approximately 1-2 hours, and
is followed by a high fever. Finally, the patient
experiences excessive diaphoresis, and the body
temperature of the patient drops to normal or below
normal
Less common symptoms include the following:
Anorexia and lethargy
Nausea and vomiting
Diarrhea
Headache

Laboratory examination

Giemsa-stained thick and thin peripheral blood smears

These smears are the criterion standard for malaria
detection and should be sent to the laboratory
immediately, since malaria is a potentially lifethreatening infection.
When reading the smear, 200-300 oil-immersion
fields should be examined (more if the patient
recently has taken prophylactic medication, because
this temporarily may decrease parasitemia).
Rapid diagnosis test
PF test, ICT test, paracheck, OptiMAL

Manifestations of Severe Falciparum Malaria

Signs

Manifestations

Unarousable coma/cerebral malaria

Failure to localize or respond appropriately to noxious stimuli; coma persisting for >30 min after
generalized convulsion

Acidemia/acidosis

Arterial pH <7.25 or plasma bicarbonate level of <15 mmol/L; venous lactate level of >15 mmol/L
manifests as labored deep breathing, often termed "respiratory distress"

Severe normochromic, normocytic

anemia

Hematocrit of <15% or hemoglobin level of <50 g/L (<5 g/dL) with parasitemia level of >100,000/mL

Renal failure

Urine output (24 h) of <400 mL in adults or <12 mL/kg in children; no improvement with
rehydration; serum creatinine level of >265 mmol/L (>3.0 mg/dL)

ARDS

Noncardiogenic pulmonary edema, often aggravated by overhydration

Hypoglycemia

Plasma glucose level of <2.2 mmol/L (<40 mg/dL)

Hypotension/shock

Systolic blood pressure of <50 mmHg in children 1-5 years or <80 mmHg in adults; core/skin
temperature difference of >10C

Bleeding/disseminated intravascular
coagulation

Significant bleeding and hemorrhage from the gums, nose, and gastrointestinal tract and/or
evidence of disseminated intravascular coagulation

Convulsions

More than two generalized seizures in 24 h

Hemoglobinuriaa

Macroscopic black, brown, or red urine; not associated with effects of oxidant drugs and red
blood cell enzyme defects (such as G6PD deficiency)

Other
Impaired consciousness

Obtunded but arousable

Extreme weakness

Prostration

Hyperparasitemia

Parasitemia level of >5% in nonimmune patients

Jaundice

Serum bilirubin level of >50 mmol/L (>3.0 mg/dL)

a Hemoglobinuria may occur in uncomplicated malaria.

NOTE: G6PD, glucose-6-phosphate dehydrogenase.

Differential Diagnosis
Typhoid fever
Dengue Fever
URTI
Leptospirosis

ALGORITME MALARIA CASE MANAGEMENT

Microscopic Exam
No Rapid Test &
No Microsc

Rapid Test ( Yes) &

No Microscopic
Vivax

Mixed/F+V

Falciparum

Rapid Test +

Rapid Test -

Microscopic Confirmation

No evidence :
URTI
TYPHOID
UTI
DENGUE
Leptospirosis
Other Infection

STEP. I: CQ3+PQ14

MILD /
MODERATE

Step. I: CQ3+PQ1
Step. II: QN7+PQ14

Step. III: CQ1+PQ1/ week

Step. II: QN7+PQ1

Parasite ++++/>5% or
/+complications ;
Cerebral

Icteric, Bil > 3mg%

Systolic <70 mmHg

Step. II: SP1+PQ1

Step. I: CQ3+PQ1

SEVERE

Breathless/ Resp > 35

No evidence :
URTI
TYPHOID
UTI
DENGUE
Leptospirosis
Other Infection

Oliguria+Creat> 3 mg%

Step. III: QN7+PQ1

SEVERE
Malaria
Treatment

Step. I: CQ3+PQ1

Management of Severe Malaria

Initial management of Severe Malaria

Clear & maintain airway

Position semiprone or on side
Weight patient, calculate dosage
Start antimalarial chemotherapy
Make rapid clinical assesment
Exclude or treat hypoglycaemia
Asses state of dehydration
Measure & monitor urine output, if nes. Catheter, S.G
Diagnostic smear, rapid test, other lab test
Plan first 8 hrs i.v. fluid, including anti malarial, glucose, blood
trasfussion
Consider CVP line
If temp. rectal > 39 C, r. clothes, tepid sp., fan, cooling
Lumbal puncture, to exclude meningitis
Anti convulsant, anti-microbials, vit.K

SPECIFIC TREATMENT SEVERE

MALARIA ( Anti Malaria)
PARENTERAL
START IMMEDIATELY
DOSAGE, WEIGHT THE PATIENT
MONITORING RESPONSE
SWITCHED TO ORAL WHEN POSSIBLE
MONITORING SIDE EFFECTS

ANTI MALARIAL THERAPY FOR S.M

QUININE
QUINIDINE
CHLOROQUINE
ARTEMISININ :

ARTESUNATE : I.V/ I.M / SUPPOSITORIES

ARTEMETHER : I.M
ARTEMISININ SUPP

RECOMMENDED DOSES OF ANTI MALARIAL

DRUGS FOR TREATMENT OF
SEVERE/CEREBRAL MALARIA
DRUGS
Quinine

SIDE EFFECTS
20 mg of dihydrochloride salt/kg by iv
infusion over 4 hr, then after
loading, followed by 10 mg/kg over
4 hr every 8 hr. Patients should not
received quinine or mefloquine
within last 24 hr
Alternatively, 7 mg of salt/kg can be
infused over a period of 30 min,
followed by 10 mg salt/kg over a
period of 4 hr, or
10 mg of salt/kg (500 mg for adult) by
i.v infusion over 8 hr continously 3 x
a day

Hypoglycemia, chinchonism,
tinnitus, hearing
impairment, nausea,
dysphoria, vomiting,
prolonged QT interval,
dysrhythmias,
hypotension

RECOMMENDED DOSES OF ANTI MALARIAL

DRUGS FOR TREATMENT OF
SEVERE/CEREBRAL MALARIA
DRUGS
Artemeter

Artemisinin

Chloroquine

SIDE EFFECTS

3.2 mg/kg im initially, followed by

1.6 mg/kg daily. Not to be
given iv (1 amp = 80 mg)
Suppositories, 10 mg/kg at 0 & 4
hr followed by 7 mg/kg at
24,36,48 & 60 hrs.
10 mg base/kg infusion at
constant rate over 8 hrs
followed by 15 mg/kg over 24
hrs, or
3.5 mg base/kg 6 hourly or 2.5 mg
base/kg 4 hourly by im or sc
injection. Total dose 25 mg
base /kg

Hypotension

Artesunate

2,4 mg/Kg/ with 3-5 ml 5% Dekstrose, IV in 2

minutes. Repeat in 12 hours.
Then every 24 hours with same dose
Oral Preparations after the patient can eat
and drink well

Convulsions

I.v. diazepam 10 mg adult or rectal 0.5-1.0

mg/kg
i.m paraldehyde o.1 mg/kg adult
Repeated conv- chlormethiazol infussion 0.8 %,
Phenytoin 5 mg/kg i.v. 20 minutes
Fosphenytoin 7.5 mg/kg i.v 20 mnutes

HYPOGLYCAEMIA ( Bl. Sugar < 40 mg% )

Coma, 20 -50 ml 50% dextrose i.v. 5 10 minutes (

routine is not recommended )
Infussion 10 % dextrose ( children 5% dextrose)
beware hyponatremia
Hypoglycaemia may developed Day 1 --- 7
Pushed 50% dextrose if necessary
Via nasogastric , beware gastric distension
In peritoneal dialysis, add glucose in dialysis fluid

Prophylaxis and Self-Treatment for Malaria

Drug Prophylaxis

Usage

Adult Dosage

Child Dosage

Mefloquine

Used in areas where chloroquine-resistant malaria has

been reported

228 mg of base (250 mg of salt) orally,

once/weeka

<15 kg: 4.6 mg of base/kg (5 mg of

salt/kg)
15-19 kg: 1/4tablet/week
20-30 kg: 1/2tablet/week
31-45 kg: 3/4tablet/week
>45 kg: 1 tablet/week

Doxycyclineb

Used as alternative to mefloquine

100 mg orally, once/day

>8 years of age: 2 mg/kg per day orally;

maximum dose, 100 mg/d

Chloroquine

Used in areas where chloroquine-resistant malaria has

not been reported

300 mg of base (500 mg of salt) orally,

once/week

5 mg of base/kg (8.3 mg of salt/kg) orally,

once/week; maximum dose, 300
mg of base

Proguanil (not available

in U.S.)

Used simultaneously with chloroquine as alternative to

mefloquine or doxycycline

200 mg orally, once/day, in

combination with weekly
chloroquine

<2 years: 50 mg/d

2-6 years: 100 mg/d
7-10 years: 150 mg/d
>10 years: 200 mg/d

Primaquinec

Used for travelers only after testing for G6PD

deficiency; postexposure prevention for
relapsing malaria or prophylaxis

Postexposure: 15 mg of base (26.3 mg

of salt) orally, once/day for 14
days
Prophylaxis: 30 mg of base daily

0.3 mg of base/kg (0.5 mg of salt/kg)

orally, once/day for 14 days

Atovaquone-proguanilc

Used as alternative to mefloquine

250/100 mg orally once/day

11-20 kg 62.5 mg/100 mg

21-30 kg 125 mg/50 mg
31-40 kg 187.5 mg/75 mg
>40 kg 250 mg/100 mg

In areas with chloroquine-resistant malaria, should be

carried during travel by persons taking
mefloquine or doxycycline

3 tablets (75 mg of pyrimethamine and

1500 mg of sulfadoxine) orally,
as a single dose

5-10 kg: 1/2tablet

11-20 kg: 1 tablet
21-30 kg: 1 1/2tablets
31-45 kg: 2 tablets
>45 kg: 3 tablets

Self-treatment
Pyrimethaminesulfadoxined

a Tablets manufactured outside the United States contain 250 mg of base.

b Not in pregnant women or children <8 years old.
c Primaquine and atovaquone-proguanil have both proved safe and effective for antimalarial chemoprophylaxis in areas with
chloroquine-resistant falciparum malaria, but more data are needed, particularly in children. These drugs should not be used
in pregnancy.
d Regimen is used for treatment only, not prophylaxis.