This presentation is only for educational purpose...:)

2. Malaria
• Agent
– Plasmodium falciparum
– P. vivax
– P. ovale
– P. malariae
• Transmission-by the bite of female anopheles
mosquitoes
• Occurs throughout the tropics and subtropics at
altitudes below 1500 meters

3. Distributions of malaria

4. Distribution of falciparum

5. Drug resistant Malaria
Red - chloroquine resistant
Green - chloroquine sensitive
Black - chloroquine and mefloquine
resistant

8. 3 million deaths/yr. 1 million in Africa,
mostly children below the age of 5

9. Pathology
• Hemolysis of infected red cells and adherence of infected cell to
capillary wall
• Hemolytic anaemia
• dyserythropoiesis,
• splenomegaly
• depletion of folate stores
• P. vivax and P. ovale invade reticulocytes
• P. malariae normoblastsmost
• P. falciparum
• invades red cells of all ages but especially young cells
• red cells containing schizonts adhere to capillary endothelium in
brain, kidney, liver, lungs and gut
• Malaria immune population
• haemoglobin F, C or especially S –falciparum
• lack the Duffy blood group – ovale

10. Pathology

11. Pathology

12. Electronmicroscope view of gut
of mosquito

13. Life cycle of malaria parasite
• Female anopheles feed on human blood containing gametocytes
(Sexual form)
• Complete sexual cycle in mosquito in 7-10 days and become
sporozoites
• Sporozoites inoculated by bite of infected mosquito
• Sporozoites leave the blood stream and enter into the hepatocyte
within half and hour
• Hepatocytes brust after few days and release merozoites
• Merozoites enter into RBCs and multiplication to complete the
asexual life cycle
• Merozoites develop into schizont in RBC and release more
merozoites in the blood and peak fever coincide to this time
• Ovale and vivex may persist in liver cells as dermant forms called
hypnozoites and capable of producing merozoites months or years
later

14. Incubation period and fever
P. vivax/ P. ovale 8-25 days / Tertian
P. malariae 15-30 days / Quartan
P. falciparum 8-25 days / Aperiodic

15. Clinical features
• P. vivax and P. ovale
• Fever with a rigor
• Feeling of cold
• Development of high fever
• Hot or flush phage
• Profuse sweating and gradual fall in fever
• Cycle is repeated 48 hours later
• Spleen and liver enlarge
• Anaemia
• Frequent Relapses in the 1st
2 years

16. Clinical features
P. malariae
Mild symptoms
Bouts of fever every third day.
Parasitaemia may persist for many years with
recrudescence of fever, or without producing any
symptoms
Causes glomerulonephritis and the nephrotic syndrome
in children

17. P. FALCIPARUM
• Most dangerous of the malarias
• Onset -insidious, with malaise, headache and
vomiting, and is often mistaken for influenza.
• Cough and mild diarrhoea are also common.
• The fever has no particular pattern.
• Jaundice is common due to haemolysis and hepatic
dysfunction.
• The liver and spleen enlarge and become tender.
• Anaemia develops rapidly.
• Develop dangerous complications

18. P Falciparum

19. Complications of falciparum
malaria
Unarousable coma/ convulsion /cerebral malaria
Acidemia/acidosis -Arterial pH <7.25 or plasma
bicarbonate level of <15 mmol/L
Severe normochromic, normocytic anemia
Renal failure -Urine output (24 h) of <400 mL in
adults or <12 mL/kg in children

20. Complications of falciparum
malaria
Pulmonary edema
Noncardiogenic pulmonary edema/adult
respiratory distress syndrome
Hypoglycemia
Hypotension/shock
Bleeding/disseminated intravascular coagulation
Hemoglobinuria /
Macroscopic black, brown, or
red urine

21. Cerebral malaria
• Severe form of malaria
• Coma is a characteristic and ominous feature
• Despite treatment, is associated with death rates of
~20% among adults and 15% among children.
• Diffuse symmetric manifestation of encephalopathy
• Focal neurology unusal

22. Cerebral malaria
• No signs of meningeal irritation but resistant to passive
neck flexion
• Tonic clonic convulsions
• Deep coma
• Patient recovering may develop sequale( <3% in adult and
about 15% in child)
• Hemiplesia
• Cerebral palsy
• Cortical blindness
• Deafness
• Cognitive and learning defect

23. Features indicating poor prognosis
in falciparum malaria
Clinical Parameter
Marked agitation
 Hyperventilation (respiratory distress)
Hypothermia (<36.5°C)
Bleeding
Deep coma
Repeated convulsions
Anuria
Shock

24. Laboratory parameter
Biochemistry
Hypoglycemia (<2.2 mmol/L)
Hyperlactatemia (>5 mmol/L)
Acidosis (arterial pH <7.3, HCO3 <15 mmol/L)
Elevated serum creatinine (>265 mol/L)
Elevated total bilirubin (>50 mol/L)
Elevated liver enzymes (AST/ALT X 3 times )
Elevated muscle enzymes (CPK , myoglobin )
Elevated urate (>600 mol/L)

25. Laboratory parameter
 Hematology
Leukocytosis (>12,000/L)
Severe anemia (PCV <15%)
Coagulopathy
Decreased platelet count (<50,000/L)
Prolonged prothrombin time (>3 s)
Prolonged partial thromboplastin time
Decreased fibrinogen (<200 mg/dL)

26. Diagnosis of Malaria

27. Diagnosis
• Thick blood film
• Low parasitemia- thick film erythrocytes are lysed,
releasing all blood stages of the parasite
• Thin film
• confirm the diagnosis,
• to identify the species of parasite
• P. falciparum, only ring forms
• Immunochromatographic 'dipstick' tests or
plasmodium LDH test

28. Management
• P. vivax, P. ovale and P. malariae
• Chloroquine: 600 mg chloroquine base followed by 300
mg base in 6 hours, then 150 mg base 12-hourly for 2
more days
• Mild falciparum malaria
• Quinine dihydrochloride or sulphate drug of choice
-600 mg salt (10 mg/kg) 8-hourly by mouth is given
until the patient is clinically better ,followed by a single
dose of sulfadoxine 1.5 g combined with pyrimethamine
75 mg, i.e. 3 tablets of Fansidar

29. Management of mild falciparum
• Sulphonamide sensitivity
• quinine may be followed by doxycycline 100 mg daily for 7 days
• Atovaquone 250 mg plus proguanil 100 mg (Malarone)
• 4 tablets once daily for 3 days
• Artemether plus Mefloquine
• Artemether 200 mg/day orally for 5 days then mefloquine 500 mg in 2
doses 2 hours apart
• Pregnancy a 7-day course of quinine alone

30. Management of severe malaria
• Early and appropriate antimalarial drugs
• Active treatment of complications
• Correction of fluid, electrolyte
• Acid-base balance
• Avoid hypoglycemia
• Avoidance of harmful ancillary treatments

31. Radical cure of malaria
• P. vivax and P. ovale
• Primaquine (15 mg daily for 14 days)
• Destroys the hypnozoite phase in the liver
• S/E-
• Haemolysis (G6PD)-deficient
• Cyanosis due to the formation of methaemoglobin

32. Chemoprophylaxis of malaria
• Chloroquine resistance high
• Mefloquine 250 mg once weekly
• Doxycycline 100 mg daily
• Malarone 100 mg daily
• 1 tablet from 1-2 days before travelling to 1 week after return
• Chloroquine resistance moderate
• Chloroquine plus Proguanil 150 mg base+100 mg (Two tablets
weekly+Two tablets daily )
• Chloroquine resistance absent
• Chloroquine or Proguanil 150 mg base or 100 mg (Two
tablets weekly/One or two tablets daily)

33. Malaria control in endemic areas
• Sanitation and improvement in living condition
• Avoid mosquito bites
• Permethrin-impregnated bed nets
• DDT and insecticide spray
• Malaria vaccine under evaluation, in Thailand and
Africa

34. Prevention

35. Prevention

36. Personal protection against
malaria
• Avoidance of exposure to mosquitoes at their peak
feeding times (usually dusk and dawn) and
throughout the night
• Insect repellents creams
• Suitable clothing – full sleeve
• Widespread use of insecticide-impregnated bed nets
or other materials