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Dr.

Sathaporn Kunnathum
21 January 2010
The patient does not care about your science;
what he wants to know is, can you cure him? 
 ~Martin H.
Fischer
Dengue Infection
transmitted by the bite of an Aedes mosquito
infected with any one of the four dengue
viruses.
Clinical disease course
Dengue fever is usually a self-limiting
disease
DHF/DSS occurs mostly in endemic areas

Outcome of DHF/DSS improved with early


diagnosis and treatment
Case definition for dengue fever
An acute febrile illness with 2 or more of
the following manifestations:
-        Headache
-         Retro-orbital pain
-         Myalgia
-         Arthralgia
-         Rash
-         Haemorrhagic manifestations
-         Leucopenia
    AND HAI / IgG ELISA antibody titre ≥ 1280 or
positive IgM in late acute or convalescent serum
Case definition for
Dengue Haemorrhagic Fever (DHF)
ALL 4 MUST BE PRESENT:
1. Fever
2. Haemorrhagic tendencies
3. Thrombocytopenia (100 x 109 /L or less)
4. Objective evidence of plasma leakage
caused by increased vascular permeability:
− Elevated haematocrit (defined as 20% or more over baseline, or a
similar drop after volume replacement therapy) or
−  Low protein; or pleural effusion or ascites
(WHO)
Case definition for
Dengue shock syndrome (DSS)
4 criteria for DHF
PLUS signs of shock:
1. rapid, weak pulse
2. narrow pulse pressure (less than
20mmHg)
3. hypotension for age
4. cold, clammy skin and restlessness
 
Treatment
Fluid rehydration
Rest
Antipyretics
Monitor BP, haematocrit, platelet count, RFT,
LFT, level of consciousness, signs of bleeding
Oxygen, sedation and blood product
transfusion as required
caused by a parasite called Plasmodium, which is transmitted
via the bites of infected mosquitoes.
Anopheles spp.
Classification
There are 4 species:
 plasmodium falciparum
 plasmodium vivax
 plasmodium ovale
 plasmodium malariae
Epidemiology
Pathogenesis
Symptoms and signs
Depends on the type of malaria:
 P. falciparum:
 The most dangerous type.
 Insidious onset.
 Malaise, headache, vomiting.
 Fever.
 Cough, diarrhea.
 Jaundice.
 Tender hepatosplenomegaly.
 Anemia develops rapidly.
Symptomology
 P.vivax and P.oval:
 Fever: classically every 48 h.
 Rigors.
 Gradual hepatosplenomegaly.
 Anemia develops slowly.
 Relapse is common.
Symptomology
P.malariea:
 Fever: every third day.
 Mild symptoms.

 Parasitaemia may persist for many years.

 Causes glomerulonephritis and nephrotic syndrome


in children.
Diagnosis
 Malaria should be suspected clinically!!
 Thick and thin blood films:
 Thick film: are 20 times more sensitive than
thin smears, but speciation may be more
difficult.
 Thin films: essential to confirm the diagnosis
and to identify the species of the parasite.
 and In P.falciparum to quantify the parasite load.
Blood films
P.falciparum P.malariea
Diagnosis
P.vivax P.ovale
Diagnosis
Immunochromatographic “dipstick” test for
P.falciparum
 should be used parallel with blood film
examination.
Prevention
Avoid mosquito bites:
Wearing long sleeves, trousers.
Nets.
Repellent creams or sprays.
UNCOMPLICATED MALARIA
Uncomplicated malaria definition:
Fever and any of the following:
Headache,
Body and joint pains
Feeling cold and sometimes shivering
Loss of appetite and sometimes
abdominal pains
Diarrhoea, nausea and vomiting.
Spleenomegaly
Uncomplicated malaria
treatment
P. falciparum malaria
The treatment of uncomplicated P. falciparum
malaria is undertaken after diagnosis of
malaria by light microscopy or Dipstick.
Patients with positive think-thick blood
smears or dipstick for P. falciparum malaria is
treated by blisters of Coartem® (artemether
20mg/lumefantrine 120mg). See Table 1 for
details of prescription.
Table 1 : Dosage and administration Coartem
(Artemether 20
mg/Lumefantrine 120 mg) for
uncomplicated
malaria falciparum
Age group Weight group Blister (Day 1) (Day 2) (Day 3)
color

4 months  5 to 14 kg Yellow 1 tb , 1 tb , 1 tb ,


to 5yrs
1 tb  1 tb  1 tb 

6 to 11y 15 to 24 kg Blue 2 tb , 2 tb , 2 tb ,

2 tb  2 tb  2 tb 

12 to 14y 25 to 34 kg Orange 3 tb , 3 tb , 3 tb ,

3 tb  3 tb  3 tb 

> 14y > 34 Green 4 tb , 4 tb , 4 tb ,

4 tb  4 tb  4 tb 

ource: Guideline for the treatment of malaria, WHO; 2006


Coartem® Dosage
Schedule

Source: WHO, 2007


Important notes (1)
1. It is obligatory to give Coartem® to patient
whose dipstick test or blood slide is positive
for P. falciparum and to the patient who has
mixed infections P. falciparum and P .vivax.
2. Give the correct dosage of Coartem® from the
appropriate blister according to the patient’s
weight or age.
3. Children under 5 kg or below 4 months should
not be given Coartem instead treat with the
following regimen (see table 2).
Table 2. Dosage and administration
Plasmodium
falciparum for young infant
Age Group Weight Artesunate or *Quinine
group

0 - 4 months <5 kg ** IM first dose  ***Oral  Oral Quinine 


Artesunate 1.2  Artesunate  10 mg/TID 
mg/kg or IM  2mg/kg/day day  for 4 days 
Arthemeter 1.6  2 to day 7 then 15-20 
mg/kg) mg/kg TID 
for 4 days

Source: Malaria in Children, Department of tropical Pediatrics, Faculty of Tropical Medicine, Mahidol University.

ferably Artesunate/Artemether IM on day 1 if available


hen Artesunate/Artemether IM is unavailable, give oral Artesunate from day 1 to
t the young infant with Quinine when oral Artesunate is not available
Important notes (2)
4. In case parasitological diagnostic facilities are not available
paracetamol could be given to relieve pain and fever and
referred to health facilities where parasitological diagnosis will
be carried out.
5. Only in exceptional case when there is problem with the
referring patient in other health facility coartem® could
be administered. (The health facility manager should
write explanatory note why giving coartem® without
parasitological diagnosis).
Important notes (3)
6. Watch all patients swallowing the first dose of
coartem® and observe for 1 hour after the
intake. In the event of vomiting within one hour
of administration, a repeat dose should be
taken.
7. Inform patient that, the coartem® tablets are in
the blister and after breaking should be taken
immediately, as after 24 hours coartem®
tablets exposed to air totally inactivated and
can not be used for treatment of malaria.
8. Each blister of coartem® has expiry date and
should not be used after the expiry date.
Important notes (4)
9. For small children, paracetamol and
coartem® can be crushed, diluted in water
and then put either directly into the mouth
using a syringe or given with a spoon.
10. Any patient who seeks re-treatment for
malaria within 2 weeks of taking full dose of
any other antimalarial should be treated
with coartem®.
Uncomplicated malaria
treatment
P. vivax malaria
 Resistance of P. vivax to chloroquine has not been
found in Timor-Leste and Chloroquine is the drug
of choice
 Chloroquine is safe and has few side effects.
 For the radical treatment of P. vivax in addition to
chloroquine, primaquine is recommended 0.5mg/kg per
day for 14 days (primaquine should always be taken
with food).
 Chloroquine can be given to pregnant women and
children.
 Primaquine is not recommended for the children
under one year and pregnant women.
• Details of treatment see table 4a.
Table 4a. Dosage and administration of
Chloroquine and Primaquine for malaria vivax.
Age Group * Weight CHLOROQUINE PRIMAQUINE
group (Kg) (150 mg base) 10 mg/kg on the (15 mg base)
first two days. 0.5 mg/kg bw
5 mg/kg on day 3
Give for 3 days Start concurrently with CQ 
and give daily for 14 days
Day 1 Day 2 Day 3

4 months up to 4 - <10 ½ ½ ¼ -
12 months
13 months up to 5  10 - <19  1 1 ½  ¼
years
6 - 7 years 19 - < 24  1½ 1½ 1 ½
8 - 11 years 24 - <35  2½ 2½ 1 ¾
12 - 14 years  35 - < 50  3 3 2 1½
15 +  50 or more 4 4 2 2
P. vivax malaria
Young infant less than 5kg or below 4
months should be treated with
Chloroquine alone for three days
consecutive (Table 4b).
Table 4b. Dosage and administration of
Chloroquine for malaria vivax in young infant

Age Weight Chloroquine


Group group

Day 1 Day 2 Day 3

0 - 4  <5 kg 10 mg/kg 5 mg/kg 5 mg/kg


months
P. falciparum and P. vivax
(mixed infections)

The type of malaria where both infections


occurs in patient requires treatment by
Coartem®.
Notes:
Negative dipstick or thin-thick blood
smear:
 If the Pf dipstick is negative and the clinical signs are
typical for malaria, treat with Chloroquine (it could
be a case of P. vivax infection).
 If the Pf dipstick is negative and the clinical signs don’t
suggest malaria, do not treat like malaria; look for another
illness.
 If the blood slide is negative, look for another illness.
 If symptoms persist, ask for another dipstick or blood slide.
 If dipstick and/or thin-thick blood smear are not
available:
 If there is no possibility of dipstick or slide results, treat the
patient based on the clinical signs and symptoms. Treat as if
the patient has P. falciparum.
Follow-up of uncomplicated
malaria:
If symptoms persist after treatment with
coartem® or if the patient comes back before the
14th day after treatment.
Treatment failure within 14 days of receiving
coartem® is extremely rare and is more likely to
be an inadequate absorption of the drug(s) than
resistance of the parasites. It is important to
determine from the patient’s history whether he or
she vomited during the previous treatment or did
not complete the full course.
If patient is in health facility where microscope is
available failure of treatment should be confirmed
parasitologically and could be treated using the
following regimen:
Follow-up of uncomplicated
malaria:
For adult:
 Quinine (10mg salt /kg bw three times a day) + doxycycline
(3.0mg/kg bw once a day) for 7 days. Do not give doxycycline with
milk or iron, which will reduce its absorption.
 If patient is in health facility where microscopy facility is not
available patient should be referred to the facility where
microscope is available. If refer is not possible treatment should
be given Quinine + Doxycycline. Please refer to Table 5 for details of the
prescription.
 Doxycycline should not be given to pregnant or lactating woman,
or child aged up to 8 years.

For pregnant or lactated woman or child less than 8 years:


 Quinine (10mg salt /kg bw three times a day) + clindamycin
(10mg/kg bw twice a day) for 7days. For small children, (quinine
and clindamycin) crush tablets and mix with water and sugar.
Note:
For high transmission areas where
parasitological confirmation is not
available, children <5 yrs of age is
recommended to be treated with anti
malarial drugs when symptomatic
(especially fever).
SEVERE MALARIA
Severe or complicated malaria
definition:
Fever and any of the following:
 Impaired consciousness
 Anxiety, palpitation and sweating
 Convulsions or fits with this fever
 Fast or difficult breathing
 Vomiting every feed / unable to feed
 Pale hands, tongue and inner parts of the eyelid
 Generalized body weakness
 Dehydration
 Jaundice
 Severe malnutrition
 Dark urine or no urine
Pre-referral treatment of
severe malaria
 A patient who is non responsive should be quickly
assessed and managed. This includes assessment
of the airway, breathing and circulation. The staff
at the first level health facility should be able to
maintain airway, provide assisted breathing and
manage shock if required.
 Pre-referral treatment for severe malaria the
administration of Artesunate by the rectal route is
recommended for all except pregnant women first
trimester pregnancy. For the complete dosage
and treatment.
 Check blood sugar, if possible!
In case Artesunate suppository is not
available IM quinine injection 20mg/kg bw
should be given. The Quinine injection dosage
should be split and injections given in the
anterior part of the thigh.
In case Artesunate suppository is not
available, give also Quinine for children
with severe malaria.
Confirmed diagnosis of
severe malaria:
 All clinically suspected severe malaria cases
require laboratory examination and
confirmation.
 Only in case where laboratory confirmation
is not possible start treatment immediately.
Parasitological confirmation is done by thin-
thick blood smear microscopy examination
or by dipstick (Rapid Diagnostic Test [RDT]).
Differential diagnosis for
complicated malaria
Consider other illnesses, such as:
Measles, meningitis, tonsillitis, dengue,
otitis media (ear infection), influenza,
pneumonia, typhoid fever, tuberculosis,
hypoglycemia.
Specific severe malaria
treatment
Artesunate (60 mg): 2.4 mg/kg body weight (bw) IV
or IM on admission (time=0), followed by 2.4 mg/kg
at 12 and 24 hours, followed by once daily for seven
days. Once the patient can tolerate oral therapy,
treatment should be switched to a complete dosage
of coartem® for three days as recommended in the
national treatment guidelines for uncomplicated
malaria .
The congenital malaria is also treated with
Artesunate, where 2.4 mg/kg is initially given
through IV, followed by 1.2 mg/kg at 12 and 24
hr then every 24 hr for 3 -5 days.
Specific severe malaria
treatment
Artemether (80mg for adult and 40 mg for
children and the newborn): 3.2 mg/kg bw IM on
the first day followed by 1.6 mg/kg bw daily for
seven days. Once the patient can tolerate oral
therapy, treatment should be switched to a
complete dosage of coartem®.
Arteether (150 mg): 3.2 mg/kg bw IM on the
first day, followed by 1.6 mg/kg bw for the next 4
days. Once the patient can tolerate oral therapy,
may switch to a complete dosage of coartem®.
If Coartem® is not available, quinine
should be administered in combination
with tetracycline or doxycycline or
clindamycin, to complete the seven-day
treatment, except for pregnant women
and children under eight years of age for
whom tetracycline/doxycycline is
contraindicated.
Quinine
Loading dose: Quinine dihydrochloride 20
mg salt/ kg bw diluted in 10 ml/kg bw of 5%
dextrose or dextrose saline administered by IV
infusion over a period of four hours for both
adult and children. In severe Childhood
falciparum malaria, if patient received quinine
or quinidine or mefloquine in 48 hrs before
arrival, give 10 mg/kg over 2 hours.
Quinine
Maintenance dose: Quinine dihydrochloride 10 mg salt/ kg body
weight diluted in 10 ml/kg body weight of 5% dextrose or dextrose
saline administered by IV infusion. In adults, the maintenance dose is
infused over a period of four hours and repeated every eight hours.
Similarly in children including congenital malaria, it is infused
over a period of two hours and repeated every eight hours
(calculated from the beginning of the previous infusion) until
the patient can swallow. To complete the seven-day to eight-
day treatment in children, give Quinine sulfate 10 mg/kg per
oral three times in a day. Increase the dosage of Quinine
sulfate to 15-20 mg/kg after 4 days or add tetracycline 5
mg/kg twice a day for children above 7 years.
Notes
 Artemisinin derivatives are safe, effective, have a
wider therapeutic window, can be administered
intramuscularly and should be considered a safer
alternative to quinine.
 A loading dose of quinine should not be given (1) if the
patient has received or suspected to have received quinine,
quinidine or mefloquine within the preceding 12 hours, and
(2) facilities for controlled rate of flow of quinine infusion
are not available. In order to improve treatment outcome of
quinine add a course of oral tetracycline 4 mg/kg bw 4 times
daily or doxycycline 3 mg/kg bw once daily except for
children under 8 years of age and pregnant women, or
clindamycin 10 mg/kg bw twice daily for 3-7 days.
 If there is no clinical improvement after 48 hours of
parenteral therapy, the maintenance dose of parenteral
quinine should be reduced by one-third to a half (i.e., 5-7
mg/kg bw quinine dihydrochloride). .
Leptospirosis
Cause : Leptospira interrogans
EPIDEMIOLOGY
1.Source of infection:
 rat,pig

clinical features:
three symptoms,
three signs,
internal organ damage,
seguelae of eyes and nerve system
PATHOGENESIS
 leptospira

 skin,mucosa
Initial stage leptospiremia toxic symptoms
 (1~3days) three symptoms:
 fever,myalgia,fatigue;
 three signs:
 conjunctival suffussion;
 muscle tenderness;
 enlargement of lymphonodes;
PATHOGENESIS
 severe toxic symptoms
 lesion of organs:
 influenza form
 pneumorrhagic form
middle stage icterohemorrhagic form
(3~10d)
 meningoencephalitis
 renal failure form.

PATHOGENESIS

 immunopathological reaction
 after fever;
 sequelae of eyes;
 reactive
 meningitis;
 cerebro arteritis
 obliterans.
 convalescent stage
PATHOLOGY
1. basic pathological change is
 infective,toxic injured of systemic
 capillaries;
 2. severe:lung,liver,kidneys,brain.
 exudation,hemorrhage,
 edema or necrosis.

Investigation
CBC
BUN/Cr , Elyte
LFT
CPK
UA
CXR
Serology
LP
Treatment
1. Supportive treatment
2. medication
- Pen G 1.6 mu iv q 6 hr
- Doxycycline (100) 1x2 o pc
- Ceftriaxone 2 g iv OD
for 7 days
Melioidosis
Cause : Burkholderia pseudomallei
Organism
Burkholderia pseudomallei
Aerobic, gram-negative
motile bacillus
Found in water and moist soil
Opportunistic pathogen
Produces exotoxins
Can survive in phagocytic cells
 Latent infections common

Center for Food Security and Public Health


Iowa State University 2005
Worldwide distribution of
melioidosis

Cheng AC and Currie BJ. Clin Microbiol Rev 2005; 18:383-416.


Transmission
Wound infection
Contact with contaminated soil or water
Ingestion
Contaminated water
Inhalation
Dust from contaminated soil
Rarely
Person-to-person
Animal-to-person

Center for Food Security and Public Health


Iowa State University 2005
Disease of rice farmers
Endemic in tropics and
subtropics
Southeast Asia, Australia, The
Middle East, India, China,
Caribbean
Rick factor
Thalassemia
Diabetes
Cirrhosis
Kidney disease
Cancer
Immune suppressed
Immunocompromise
SLE
Human Disease
Incubation period: 2 days to years
Latent infection
Most infections asymptomatic
Clinical forms
Acute pulmonary infection
 Most common
Focal infection
Septicemia
Neurological (rare)

Center for Food Security and Public Health


Iowa State University 2005
Investigation
CBC
BUN/Cr
LFT
CPK
UA
CXR
Serology
LP
H/C
Imagine study
Treatment
1. Supportive treatment
2. Specific treatment
2 weeks Ceftazidime 2g iv q 8 hr +-
Bactrim 2 amp iv q 8 hr
then Bactrim 2x3 o pc + doxycycline 1x2 o
pc until 20 weeks
Parasite
Treatment
Albendazole(200) 2 x 1 O pc 5 days
Ivermectin 0.2 mg/kg single dose
Praziquantel 40 mg/kg single dose
Body and soul cannot be separated for
purposes of treatment, for they are one and
indivisible.  Sick minds must be healed as well
as sick bodies. 
 ~C.
Jeff Miller
Thank you
for your attention