Severe And Complicated

Malaria
.

Moderator: Dr.Melkamu
. Feb,2015
. 2

severe and complicated malaria

 By
 Abdulkadir Mawol
 Abel Handebo
 Abrham Zeleke
 R o b a Ja l e t a
 Abdulahi mohamed
Outline 3

severe and complicated malaria

 Objectives
 Introduction
 Etiology and mode of transmission
 Life cycle of the plasmodium
 Pathogenesis
 Clinical manifestation
 Complication
 severe and complicated malaria
 Diagnosis
 Prevention
 Management
Objectives 4

severe and complicated malaria

 To describe epidemiological status of malaria
in the world and in Ethiopia.
 To explain the etiology, mode of
transmission, and pathogenesis of malaria.
 To define severe and complicated malaria.
 To describe the diagnostic approaches and
prevention measures of malaria.
 To describe the management principles of
severe and complicated malaria.
Introduction 5

severe and complicated malaria

 Malaria is an acute and chronic illness characterized by
paroxysms of fever, chills, sweats, fatigue, anemia, and
splenomegaly.
 Malaria is a major worldwide problem occurring in >100 countries
with a combined population of >1.6 billion people.
 Malaria in the developing world today, with an estimated 300–500
million cases and >1 million deaths each year.
 Most malarial deaths occur among infants and young children
 Approximately 52 million people (68%) live in malaria risk areas
in Ethiopia, primarily at altitudes below 2,000 meters.
 severe and complicated malaria
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 severe and complicated malaria
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Malaria situation in Ethiopia 8

severe and complicated malaria

 Highly seasonal (unstable)
 Mainly depends on rain fall and temperature.
 Two major transmission periods
 September to December after main rainy

season.
 April to June following small showers of

rain in autumn.
 severe and complicated malaria
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BY;ABEL HANDEBO
…....
Etiology and Transmission 10

severe and complicated malaria

 P.falciparum = 60%
 P.vivax = nearly 40%
 P.malariae and P.ovale = 1% and less than 1% for
respectively.

 Mode of transmission
 By the bite of female anopheline mosquitoes (A.arabiensis )
 Blood transfusion (Transfusion malaria):
 Mother to the growing fetus (congenital malaria)
Life cycle of the plasmodium 11

severe and complicated malaria

 They are obligate intracellular organisms.
 Plasmodium species have a complex life cycle.
 Need two hosts to complete life cycle :
o Human =asexual phase… (IH)
o Female Anopheles mosquitoes =sexual phase…(DH)
 In human, the reproduction process have 2 phases:
o Phase I/exoerythrocytic phase
 Takes place in hepatocytes
 It begins with inoculation of sporozoites into the
bloodstream
Cont’d… 12

severe and complicated malaria

 Within minutes, the sporozoites enter the hepatocytes
where they develop and multiply asexually as a schizont.

 1–2 wk, the hepatocytes rupture and release thousands of

merozoites into the circulation.

 Tissue schizonts for P. ovale and P. vivax ;

 Primary type ruptures in 6-9 days
 Secondary type remain dormant
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severe and complicated malaria

.
Cont’d… 14

severe and complicated malaria

 Phase II/erythrocytic phase
 Takes place in RBCs
 Merozoites from the liver penetrate
erythrocytes.
 Inside erythrocyte, the parasite transforms
into the ring form.
 which then enlarges to become a
trophozoite.
Cont’d…
 The trophozoite multiplies asexually to produce a

severe and complicated malaria

number of small erythrocytic merozoites.

 Finally, that are released into the bloodstream when

the erythrocyte membrane ruptures.

 Over time, some of the merozoites develop into male and

female gametocytes.

 Then, they are ingested during a blood meal by the female

Anopheline mosquito.
14
16
Cont’d… 17

severe and complicated malaria

 The male and female gametocytes fuse to form a
zygote in the stomach cavity of the mosquito.

 After a series of further transformations,

sporozoites enter the salivary gland of the
mosquito.

 Finally, are inoculated into a new host with the

next blood meal of the mosquito.
Pathogenesis 18

severe and complicated malaria

 Four important pathologic processes have been identified in
patients with malaria:
1.Fever
erythrocyte rupture and release of merozoites into the circulation.
2. Anemia
hemolysis, sequestration of erythrocytes in the spleen and other
organs.
3.Immunopathologic events polyclonal activation
• Hypergammaglobulinemia
• formation of immune complexes.
Cont’d… 19

severe and complicated malaria

o immunodepression,.
o excessive production of proinflammatory
cytokines.
4.Tissue hypoxia
Cytoadherence of infected erythrocytes to
vascular endothelium occurs with P.
falciparum malaria.
 lead to obstruction of blood flow
 lactic acidosis
Cont’d… 20

severe and complicated malaria

 Extracellular Plasmodium organisms are targeted by
antibody.
 Intracellular organisms are targeted by CMI.

 Conditions that enhance resistance

 RBCs containing hemoglobin S
 RBCs lacking Duffy blood group antigen (P. vivax)
 RBCs containing hemoglobin F (fetal hemoglobin)
and ovalocytes (P. falciparum)
21

severe and complicated malaria

…...
Clinical manifestations 22

severe and complicated malaria

 The incubation periods for
 P. falciparum = 9–14 days
 P. vivax = 12–17 days
 P. ovale = 16–18 days
 P. malariae = 18–40 days.
 A Prodromal symptoms
 headache, fatigue, anorexia, myalgia,
slight fever, and pain in the chest,
abdomen, and joints.
Cont’d… 23

severe and complicated malaria

 The classic presentation of malaria, febrile
paroxysms are characterized by :

 high fever,
 rigors, sweats, and headache,
 myalgia, back pain, abdominal pain,
 nausea, vomiting, diarrhea,
 pallor, and jaundice.
Complications 24

severe and complicated malaria

 Cerebral malaria
o Occur among patients with parsitemia of greater than 5%
o Decreased level of consciousness; severity ranges from drowsiness & sever
headache to confusion, delirium, hallucination or deep coma .
o Physical finding
 Fever
 Abnormal body movement
 Contacted(unequal pupil)
 Retinal hemorrhage
 Hemiplegic
 Positive babeniski sign
 Increased CSF protein
Cont’d… 25

severe and complicated malaria

 Severe anemia(hemoglobin <5g/dl, haemocrit <
15%)
 Hypoglycemia(<40 mg/dL)
 Metabolic acidosis(bicarbonate <15 mmol/L)
 Acute tubular necrosis
 Pulmonary edema
 Shock or “algid malaria”(systolic BP < 80 mmHg)
 Thrombocytopenia(10,000-20,000/mm3 )
 Splenic rupture…
Severe and complicated malaria 26

severe and complicated malaria

 Is defined as a blood film proven P. falciparum
malaria with the following features(severity signs)

 Impaired consciousness or coma

 Patient sleepy, confused, unable to walk or sit-
up
 failure to feed
 Multiple Convulsion, or recent history of
convulsion
Cont’d… 27

severe and complicated malaria

 Spontaneous bleeding; gum bleeding, epistaxis
 Failure to pass urine in the last 24 hours
 Respiratory distress
• Grunting
• Intercostal or subcostal retractions
• Nasal flaring
• Deep breathing
• Chest indrawing
 Persistent vomiting
Cont’d… 28

severe and complicated malaria

 Dark urine
 Yellow sclera
 High fever
 Extremely pale mucosa
 Systolic blood pressure of < 80 mmHg.
29

severe and complicated malaria

BY;ABRHAM &ABDULAHI
…….
Diagnosis 30

severe and complicated malaria

 Clinical diagnosis
 Laboratory workups
 Blood film
 Thick blood film
 Thin blood film
 Immunological assays
 Hgb, Hct, CL, BGL,LP,WBC count
 Molecular studies
 PCR
Differential Dx 31

severe and complicated malaria

 Meningitis  ATN 20 hypovolemia
 Encephalitis  Relapsing fever
 Viral hepatitis  Typhoid fever
 Sepsis  Yellow fever
 Pneumonia  Amebic liver abscess
 Gastroenteritis  UTI
 Pyelonephritis  Osteomyelitis
 Glomerulonephritis  Otitis media…
Prevention 32

severe and complicated malaria

 Reduce Human-Mosquito Contact
• impregnated bed nets
• repellants, protective clothing
• house spraying

 Reduce Vector
• environmental modification
• larvacides/insecticides
• biological control

 Reduce Parasite Reservoir

• diagnosis and treatment
• chemoprophylaxis
Management of severe and 33

complicated malaria

severe and complicated malaria

 Supportive measures(A,B &C approaches)
 Check for complications and if present, treat them
 If the child is unconscious
 insert a NG tube
 Maintain clear air way
 Hypoglycemia (5 ml/kg of 10% dextrose by slow IV
infusion)
 Convulsions
o IV diazepam(0.15mg/Kg)
o Rectal diazepam(0.5-1mg/Kg)
o IM Paraldehyde(0.1ml/Kg)
Cont’d… 34

severe and complicated malaria

 Severe anemia
 Blood transfusion
 Hypovolemia, Shock, Acidosis
 Balance the fluid with Isotonic saline.
 Careful monitoring is needed to avoid fluid overload.
 Pulmonary edema
 Oxygen therapy
 Position patient upright (sitting position)
 IV furosemide
Cont’d… 35

severe and complicated malaria

 Anti malarial treatment
 First line drugs
 IV or IM artesunate (2.4 mg/kg) given on admission
(time = 0), then at 12 hrs and 24 hrs, then once a day
for 5-7 days is the recommended treatment.
 If this not available, slow IV quinine infusion is
applied.(usually diluted in 5% dextrose and infused
over four hours).
 For all patients with severe malaria, IV quinine
infusion should be given at least for the first 48 hours;
Cont’d…

severe and complicated malaria

 Once the patient with severe malaria regains
consciousness and tolerates oral therapy, oral
AL therapy(coartem) should be started and
substituted to complete therapy.
 Coartem tablet containing 120 mg
artemether plus 20 mg lumefantrine in a
fixed dose.

36
 Cont’d…
37

5-14 kg 25-34 kg

severe and complicated malaria

15-24 kg >35Kg
References 38

severe and complicated malaria

 Robert M. Kliegman, et.al. ,Nelson Text book of
Pediatrics.18th ed. Philadelphia; SAUNDERS
ELSEVIER;2007.
 FMOH, NATIONAL MALARIA
GUIDELINES.3rd ed. Addis Ababa,2012.
 FMOH, Malaria diagnosis & treatment
guideline for health workers in Ethiopia .2nd ed.
Addis Ababa,2004.
THANK YOU!
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severe and complicated malaria