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‫بسم ال الرحمن الرحيم‬

Chemotherapy of Malaria,
Leishmaniasis & Schistosomiasis

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Chemotherapy of Malaria
A. Symptomatic treatment:
• Fever Paracetamol
• Vomiting Metoclopramide or
domperidone
• Diarrhoea Loperamide
• Anaemia Iron, folic acid, blood
transfusion
• Dehydration IV fluids
• Shock Dopamine
• Oliguria Furosemide, mannitol
• Convulsions Diazepam
• Jaundice Fluid & electrolyte
replacement along with good 2
nutrition, usually sufficient
B. Specific Treatment
• Treatment of acute attack of
malaria:
a. Chloroquine sensitive (non-
resistant)
b. Chloroquine resistant
• Radical cure
Only for Pl. vivax & Pl. ovale
• Prophylaxis from malaria:
a. Chloroquine sensitive
b. Chloroquine resistant
c. Protection from mosquito
bites 3
Treatment of acute attack of
malaria
Chloroquine non-resistant malaria
 When to treat as chloroquine non-
resistant malaria?
Pl. vivax & Pl. ovale (Benign tertian
malaria)
Pl. malariae (Benign quatern malaria)
Pl. falciparum (Malignant tertian
malaria when patient come from
choloquine non-resistant area &
illness is mild)
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Treatment of chloroquine non-resistant
malaria
• Choloroquine (base):
Oral 600 mg stat, 300 mg after 8 hrs,
300 mg OD for 2 days
• Avoid parenteral Inj.
• If necessary, give slow IV infusion (risk
of hypotension & arrhythmias)
• Caution/contraindications: Epilepsy,
CHF, arrhythmias, psoriasis, porphyria,
myopathy, visual field defects
• Kaolin & antacids ↓ absorption
• If chloroquine not effective treat as
chloroquine-resistant
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Radical treatment
• Needed only for Pl vivax & Pl ovale
• Given after acute attack is controlled
with chloroquine or other drugs
• Primaquine (base) 15 mg OD for 2-3
weeks
• Effective against hypnozoites in liver
• Caution in G6PD deficiency, causes
haemolysis
• In G6PD deficient patients 30 mg/week
for 8 weeks
• Other adverse effects similar to
chloroquine 6
Chloroquine resistant malaria
 When to treat as chloroquine-resistant
malaria?
• Falciparum known & patient from
chloroquine resistant area
• Falciparum not known, patient is seriously
ill and have symptoms of cerebral malaria
(confusion, delerium, convulsions)
• Mixed infection
• Benign tertian not responding to
chloroquine
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Chloroquine resistant malaria (Cont.)
a. First line treatment:
• Quinine/quinidine +
doxycycline/clindamycin
• Quinine/quinidine
• Parenteral:
Loading dose: 20 mg/kg (up to 1.4 g) IV
over 4 hrs
Maintenance: 10 mg/kg (up to 700 mg)
IV 8 hourly
• Oral: 600 mg TID for 5-7 days
• Adv. Effects & drug interactions:
• Cinchonism (headache, dizziness, tinnitus,
vertigo, fever)
• IV infusion may cause hypotension, 8
Chloroquine resistant malaria
(Cont.)
• Doxycycline:
Parenteral: 100 mg IV BID
Oral: 200 mg OD for 7 days
• Adv. effeects:
• Bone & teeth deposition, GI upset,
hypersensitivity, super-infection
• Clindamycin (in children)

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Chloroquine resistant malaria
(Cont.)
b. Alternate regimens
i. Pyremethamine & sulphadoxine
(Fansidar), cheap
• Single dose: 75 mg + 1500 mg
• Useful against Pl. falciparum, less
effective against Pl. vivax
• Can cause megaloblastic anemia,
hypersensitivity, crystaluria & GI up-set
ii. Atovaquone & proguanil (Malarone),
costly
• Useful alternative for mixed infection
• May cause GI upset, rash, reversible ↑ 10
Chloroquine resistant malaria
(Cont.)
iii. Mefloquine:
• Effective against all types of malaria,
costly
• Single dose: 1250-1500mg
• or 750mg + 500mg after 8 hr
• Cautions: Epilepsy, psychiatric illness
(schizophrenia, depression), CHF,
arrhythmias & patients using quinidine
iv. Artemether & lumefantrine (Riamet),
very costly
Reserved for multi-drug resistant malaria11
Prophylaxis of Malaria
a. For travel to chloroquine sensitive areas
• Chloroquine 300 mg (base) /wk; can be used
as under:
• 1 wk before, throughout stay (up to 5 yrs) & 4
wks on return
b. For travel to chloroquine resistant areas:
• i. Chloroquine 300 mg /wk & proguanil 100 mg
/d (5 yrs)
• ii. Mefloquine 250 mg/wk
(1 “”)
• iii. Doxycycline 100 mg/d (6
months)
• iv. Atovaquone 250 mg & proguanil 100 mg
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daily (1-2 yrs)
Malaria during pregnancy
• Can be used:
• Chloroquine non-resistant malaria
• Chloroquine
• Chloroquine resistant malaria
• Chloroquine & proguanil
• Quinine/quinidine
• Mefloquine: avoid in 1st trimester
• Atovaquone + proguanil (Malarone): use if
necessary
• Contraindicated:
• Doxycycline
• Pyrimethamine and sulphadoxine
combination
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Prevention from mosquito
bites
• Mosquito nets; soaked in permethrin
• Coils, mats & vapors of insecticides
• Diethyl-toluamide (DET) lotion and
spray
• Long sleeves & trousers (other suitable
dress)

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Management of Leishmaniasis
• Cutaneous:
• Single skin lesion treated locally by
curettage & cryotherapy
• Multiple lesions treated like visceral,
usually for 10 days
• Muco-cutaneous & visceral or kala-
azar:
• First line treatment
• Sdium stibogluconate:
• 20mg/kg/d slow IV, deep IM for 20 days
• Adverse effects:
• ECG changes: T-wave inversion & QT
prolongation
• IM Inj. painful., IV Inj. can cause 15
Management of Leishmaniasis
(Cont.)
• Alternate drugs:
a. Amphoterricin B: 1-3 mg/kg/d for 10-20
days
• Can cause renal damage
(liposomal preparation causes renal
damage)
b. Others:
Maglomine antimonate, pentamidine,
paromomycin & miltefosine

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Management of Leishmaniasis
(Cont.)
• Secondary infection in muco-
cutaneous leishmaniasis:
• Pharyngitis & laryngitis
• Laryngeal edema & obstruction (may be
fatal)
• Treatment:
• Antibiotics (e.g. amoxicillin or amoxiclave)
• Hydrocortisone (fo laryngeal edema)

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Management of Schistosomiasis
• S. haematobium, S. mansoni & S.
japonicum
• Management strategies:
• A. Treatment of local irritation (swimmers
itch)
• B. Treatment of allergic reaction to
cercarial entry (fever, rash, myalgia,
pneumonitis - Katayama fever)
• C. Control of egg laying to prevent
complications
• D. Treatment of complications 18
Management of Schistosomiasis
(Cont.)
• Swimmers itch & Katayama fever:
• Anti-allergic (chlopheniramine),
paracetamol, steroids (prednisone or
hydrocortisone)
• Control of egg laying & complications:
• Praziquantel: Effective against all 3 forms
• ↑ entry of Ca++ to cell memb, paralyze,
detach & kill
• Taken after meal without chewing (bitter)
• May increase symptoms of Katayama
fever
(↑ allergic reaction due to dead cestodes)
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