Specifically ask / look for - fever with duration - headache
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Management ofsevere falciparum malaria
Dr SK Mishra,MDIspat General Hospital,
Rourkela 769005India
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Falciparum malaria is a potentially fatal disease
Successful treatment completely cures without disability
Early diagnosis and prompt treatment prevents fatal complications 2
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Severe malaria 1. Cerebral malaria2. Acute renal failure 3. ARDS4. Severe anaemia (Hb < 5g%)5. DIC6. Haemoglobinuria7. Hypotension, Shock8. Hyperparasitemia9. Repeated seizures10. Hyperpyrexia11. Haemolysis (Sr bil. >3 mg%)
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Diagnosis of malaria
1. History and clinical features * locality , travel history * fever * spleno-hepatomegaly * presence of complications
2. Laboratory diagnosis 3
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* Drug history* Anti malarials* Blood transfusionHistory of - haemoglobinopathy - diabetes - alcoholism/ jaundice
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Specifically ask / look for - fever with duration - headache
- vomiting, diarrhoea - urine output and colour - cough / dyspnoea/ bleeding - altered sensorium / seizures - pregnancy 5
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Clinical examination Pallor, icterus bleeding signs early signs of pulm oedema consolidation arrhythmia hepatosplenomegaly uterus 6
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CNS ExaminationSensorium /coma score- Glasgow coma score- Blantyre coma score- decerebrationPupils, Fundus examinationNeck stiffnessPlantar reflex 7
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Laboratory diagnosis
Microscopy Immunological tests Antigen capture tests Antibody detection tests QBC test DNA probe PCR 8
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Microscopygold standard for diagnosisthick smear: rapid diagnosisthin : species identification
other advantage- platelets, anaemia, toxic picture
If negative : repeat blood test 6 hourly for 6 times
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Why parasites are not detected at times in peripheral smear ?a. sequestration in deep vascular bedb. partially treated patientsc. prophylactic antimalarial treatmentd. inexperienced microscopiste. poor quality staining
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Antigen capture tests* Pf-ICT test * Parasight-F test/ Malacheck etcPrinciple: dipstick antigen capture assay employs a monoclonal antibody detecting the Pf.HRP-2 antigen in the bloodRapid, simple, sensitive testSpecies specificity 11
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Antibody detection test- RIA - ELISAantibody persists for a long time so not helpful in acute infection
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QBC testSpinning blood in a specialised capillary tubes in which parasite DNA is stained with acridine orange.Detected by ultraviolet microscopeSensitive and specific (?) inExperienced hands
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PCR testSensitiveCan identify different speciesTakes 48- 72 hoursExpensiveAvailable in selected places only
DNA Probes 14
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Cerebral malariaComa scoringExclude other causes of coma
1. ABC of coma care2. Prompt institution of antimalarials3. Treatment of hyperpyrexia4. Management of other complications5. Treatment of associated infections 17
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Antimalarial therapy
Parenteral therapy is a must asrapid parasitecidal action is warrantedMainstay of therapy is Quinine- Loading dose or not ?- IV is the route of choice - Donot reduce the dose in first 48 hours of quinine therapy- 20% renal and 80% hepatic clearance
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Quinine therapy
10 mg/ kg body weight over 4 hours every 8 hourly in DNS or dextrose.
If therapy has to continue beyond 48 hours reduce dose to 2/3rd.
T 1/2 healthy subjects - 11 hours uncomplicated patients 16 hours cerebral malaria - 18 hours
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Side effects:Minor: cinchonism, tinnitus deafness, vertigo, vomitingdoes not require stoppage of quinine treatment.
Severe: hypoglycemia, DIC,haemolysis, arrhythmia, thrombocytopenia etc. These complications are rare.
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Artemisinine compounds Rapid schizonticidal drugArteether (E-mal) inj150 mg deep im od x 3 daysArtemether (Larither)Inj 80 mg im bid x 3 daysor Inj. 80 mg bid first day then od x 4 daysArtesunate (falcigo)Unstable, to be prepared before administration 2.4 mg/kg first dosem then 1.2 mg 12 hr then daily for 3-4 days 21
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COMMON ERRORS INMANAGEMENT OFSEVERE MALARIA 1.Failure to diagnose associated complications such as bacterialinfections, eclampsia, Gram negative septicemia etc.2. Missed hypoglycaemia3. Misjudgement of severity
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4.Errors of fluid and electrolytic replacement5.Errors in anti-malarial chemotherapy6. Delay in starting treatment Unjustified withholding of antimalarial drug for the fear of toxicity e.g. Quinine in pregnant women, in hypoglycaemia-Inadequate dosage administration-Failure to control the rate of IV infusion 23
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7. Delay in considering obstetrics intervention pregnant women suffering from malaria
8.Missed / late diagnosis of ARDS, acute pulmonary oedema
9 Use of inappropriate ancillary therapies e.g. steroids, .
10. Delay in starting dialysis24
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This lecture is prepared exclusively for
Supercourse