1. MALARIA 2 malaria in adults diagnosis and management

2. Plasmodium falciparum Most common cause of severe- life threatening malaria. Kills over 0ne million people annually Affects all ages Mortality depends on age, immunity etc complications and access to effective treatment Mortality is higher in adults than in children

3. SEVERE MALARIA IN ADULTS Non immune ---travellers Return to endemic area after prolonged absence Stopping prolonged life-long prophylaxis HIV patients Pregnant women

4. Pathophysiology Mainly effects on Bood and capillaries. 1)HAEMOLYSIS --ALWAYS Therefore --ALL TISSUES --- ANOXIA 2)Infected red cells adhere to capillary walls esp brain, gut, lungs, kidneys---ANOXIC DAMAGE 3)Toxins from liberated shizonts further damage MALARIA--MULTIORGAN INVOVEMENT

5. DIAGNOSIS- Clinical Great mimic of diseases common in the tropics Great index of suspicion in all febrile conditions esp if cause not obvious In many cases not dramatic start --insidious --malaise , headache, vomitting Cough & diarrhoea Fever--no pattern and may not be high

6. Diagnosis Jaundice Dark urine Tender hepatosplenomegaly Some apparently not so ill pts can develop severe malaria ie serious complications HISTORY TRAVEL history -- within and from without Transfusion Injection (contaminated needle)

7. Differential diagnosis of severe malaria Septicaemia Typhoid fever, Pyelonephritis Influenza, Lobar pneumonia Viral hepatitis Meningitis Encephalitis esp in non-immune. Drug effects and poisoning

8. Features indicating severe malaria CLINICAL FEATURES Impaired consciousness Respiratory distress, acidosis, ARDS, pulmonary oedema Jaundice Bleeding Shock or circulatory collapse

9. HAEMATOLOGICAL FEATURES Parasitaemia= or more than 5% or +3 or more Haemoglobin less than 6g/l or haematocrit less than 20% 5% or more neutrophils contain malaria pigment Presence of schizonts of P falciparum in peripheral blood smear Evidence of DIC

10. TREATMET uncomplicated Amodiaquine –artesunate combination – (oral) National recommendation for three days. Not recommended for pregnant women in 1st trimester May be used after 1st trimester Use quinine oral for pregnant women 600m oral 8hly for 7days

11. Alternative to artimisimin-amodiaquine Artimisimin-lumefantrine----(coartem) Safer more expensive. Lumefantrine is not cardiotoxic, does not lower BP and no reported serious neurological or haematological complications

12. Principles of management of severe malaria SPECIFIC ANTIMALARIALS-- parenteral Symptomatic support Management of complications

13. Chemotherapy Quinine dihydrochloride--IV slow loading dose infusion over 4 hours (NEVER BOLUS) omit LD if pt has had quinine, quinidine or halofantrine in preceeding 24hrs or mefloquineinpreceeding 7 days followed by maintenamce dose 8 hourly in dextrose solution infused over 4-6 hrs Replace iv with oral after 48hrs Total duration 7-10 days. ECG if possible

14. ALTERNATIVE TO QUININE Intramuscular artemisimin --artemether slow absorption from im depot Faster parasite clearance Not cardiotoxic Limited studies but as effective as quinine No advantage in mortality Further evaluation

15. Problems with antimalarial drugs Chloroquine --high resistance rate Ghana about 20% Quinine – good for severe malaria.. Cardio depressnt, hypotension and arrythmias. Mefloquine --good but some resistance, cardiac depressant and neuropsychiatric adverse effects Halofantrine – can cause death from arrythmias but good antimalarials no in wide use. Lumefantrine. Good, has no cardiac depressant effects but expensive . Marketted with artisunate as Co-actem. Sulphadoxine-Pyrimethamine not recommended to individuals sensitive to sulphonamides or individuals with G6PD deficiency.

16. Intermittent Preventive Treatment IPT used to prevent malaria in pregnancy (1)after 16 weeks SP therapeutic dose 3 tablets. 2) second dose one month later (3) Third dose one month later. Danger of sp folate deficiency, hypersensitivity Amodiaquine– similar to chloroquine, hypotension and syncope common, dystonicreations observed in Ghana, agranulocytosis reported in Western countries. Artimisimin derivatives effective. No reported resistance and no major adverse reactions. expensive

17. General Measures severe malaria Good nursing Exclude other treatable causes of coma Rapid initial check of blood sugar frequent checks Monitor fluid balance avoid over & and under hydration Monitor urine output and look for haemoglobiuria Reduce temp by sponging avoid asprin & NSAID Look for associated infections and Rx Look for complications

18. COMPLICATIONS DAMAGE DUE TO ANOXIA Brain Kidneys (acute tubular necrosis) Lungs :cough pulmonary oedema Intestine: diarrhoeacongestion,leakinnes to bacteria Liver: jaundice may- encephalopathy

19. Complications Intravascular haemolysisBlackwater fever Shock hypotensive Septcaemic shock Hypoglycaemiaesp with quinine Rx or in pregnancy Metaboliic acidosis rare in adults Splenic rupture DIC In pregnancy maternal death abortion, still birth low birth wt

20. Adult mortality high Renal failure Pulmonary oedema Cerbral complications for non immune In Pregnancy