1. Malaria
MALARIA CLINICAL PREASENTION, INVESTIGATION AND
TREATMENT
BY ALINISWE NG’AMBI

2. How Malaria present Clinically
 Stage 1(cold stage)
 Chills for 15 mt to 1 hour
 Caused due to rupture from the host red cells
escape into Blood.
 Preset with nausea, vomitting, headache
 Stage 2(hot stage)
• Fever may reach upto 400c may last for several hours starts invading newer red
cells
 Stage 3(sweating stage)
• Patent starts sweating, concludes the episode
• Cycles are frequently Asynchronous
• Paroxysms occur every 48 – 72 hours
• In P.malariae pyrexia may last for 8 hours or more and temperature my
exceed 410c

3. More commonly, the patient presents with
a combination of the following symptoms
 Chills
 Sweats
 Fever
 Headaches
 Nausea and vomiting
 Body aches
 General malaise.

4. SEVERE COMPLICATED MALARIA
 Alteration in the level of consciousness (ranging from drowsiness to
deep coma)
 Cerebral malaria (unarousable coma not attributable to any other
cause in a patient with falciparum malaria)
 Respiratory distress (metabolic acidosis bicarb less than 15 meq/l)
 Multiple generalized convulsions (2 or more episodes within a 24
hour period) Shock (circulatory collapse, septicemia)
 Pulmonary edema
 Abnormal bleeding (Disseminated Intravascular coagulopathy)
 Jaundice

5. SEVERE COMPLICATED MALARIA
 Haemoglobinuria (black water fever)
 Acute renal failure - presenting as oliguria or anuria
 Severe anaemia (Haemoglobin < 5g/dl or Haematocrit <
15%)
 High fever
 Hypoglycaemia (blood glucose level < 2.2.mmol/l) defined
as the detection of P. falciparum in the peripheral blood

6. INVESTIGATIONS AND LABS
•Baseline study
 CBC: Hemolytic anaemia: Hb, LDH, indirect bilirubin.
 Leukocytosis or leukopenia are uncommon except in severe disease
 Urinalysis:hemoglobinuria may occur with intravascular hemolysis
 OTHERS; LFT and Coagulation panel to evaluate for organ funtion
•Blood film examination(Microscopy)
• Rapid Diagnostic Tests" (RDTs)
• PCR

7. BLOOD FILM(THIN AND THICK SMEAR)

8. STAINING WITH GIEMSA STAIN

9. Antigen Detection
• These "Rapid Diagnostic Tests" (RDTs). Rapid diagnostic
tests (RDTs) are immunochromatographic tests based on
detection of specific parasite antigens. Tests which detect
histidine-rich protein 2 (HRP2) are specific for P.falciparum
while those that detect parasite lactate dehydrogenase
(pLDH)-OptiMAL

10. Molecular Diagnosis
• Parasite nucleic acids are detected using polymerase chain
reaction (PCR). This technique is more accurate than
microscopy. However, it is expensive, and requires a
specialized laboratory (even though technical advances will
likely result in field-operated PCR machines).

11. Treatment of uncomplicated p.falciparum
• Artemether plus lumefantrine( COARTEM)
• Weight Tablets Day 1 Day 2 Day3
• 5-14kgs 1 tab 1 tab 1 tab then 8hr Q12H Q12H
• 15-24kgs 2 tab 2 tab 2 tab then 8hr Q12H Q12H
• 25-34kgs 3 tab 3 tab 3 tab then 8hr Q12H Q12H
• > 34 Kgs 4 tab 4 tab 4 tab then 8hr Q12H Q12H

12. Treatment of severe falciparum malaria
Preferred regime
• IV Artesunate (60mg): 2.4mg/kg on admission, followed by 2.4mg/kg at 12h & 24h, then once
daily for 7 days.
• Once the patient can tolerate oral therapy, treatment should be switched to a complete dosage
of Coartem (artemether/lumefantrine) for 3 day.
• Reconstitute with 5% Sodium Bicarbonate & shake 2-3min until clear solution obtained. Then
add 5ml of D5% or 0.9%NaCl to create total volume of 6ml.
• Slow IV injection with rate of 3-4ml/min or IM injection to the anterior thigh. The solution
should be prepared freshly for each administration & should not be stored. Pregnant women &
child < 8yrs old: Clindamycin (10mg/kg twice daily). Both drug can be given for 7 days
• ALTERNATIVE REGIME
• IV Quinine loading 7mg salt /kg over 1hr followed by infusion quinine 10mg salt/kg over 4 hrs,
then 10mg salt/kg Q8H or IV Quinine 20mg/kg over 4 hrs, then 10mg/kg Q8H. PLUS
• Adult and child > 8yrs old ; doxycycline( 3.5 mg/kg once daily)
• Dilute injection quinine in 250ml od D5% and infused over 4hrs.
• Infusion rate should not exceed 5 mg salt/kg per hour

13. FOR UNDER FIVES
Children under 5 kg or below 4 months should not be given
Coartem instead treat with the following regimen (see table).
Age Group
Weight
group
Artesunate or *Quinine
0 - 4
months
<5 kg
** IM first dose
Artesunate 1.2
mg/kg or IM
Arthemeter 1.6
mg/kg)
***Oral
Artesunate
2mg/kg/day
day 2 to day 7
Oral
Quinine 10
mg/kgTDS
for 4 days
then 15-20
mg/kg TDS
for 4 days

14. SPECIFIC POPULATION
• Specific Preferred regime Alternative regime populations
• Pregnancy Quinine plus clindamycin to be given for Artesunate plus Clindamycin
7 day for 7 days is indicated if first
line treatment fails
• Lactating woman; Should receive standard antimalarial treatment (including ACTs) except for dapsone,
primaquine and tetracyclines, which should be withheld during lactation
• Hepatic Chloroquine: 30-50% is modified by liver, appropriate dosage adjustment impairment is needed,
monitor closely.
• Quinine : Mild to moderate hepatic impairment-no dosage adjustment, monitor closely.
• Artemisinins : No dosage adjustment
• Renal Chloroquine : ClCr<10ml/min-50% of normal dose.
Impairment Hemodialysis, peritoneal dialysis: 50% of normal dose.
Continuous Renal Replacement Therapy(CRRT) :100% of normal dose
Quinine : .ClCr 10-50ml/min : Administer Q8-12H, CLCr<10ml/min administer Q24H
,Severe chronic renal failure not on dialysis : initial dose: 600mg followed by 300mg Q12H, Hemo- or peritoneal
dialysis: administer Q24H ,Continuous arteriovenous or hemodialysis: Administer Q8-12H. Artemisinin : no
dosage adjustment.

15. Prevention
• •Avoid mosquito bites:
• Wearing long sleeves, trousers.
• Avoid mosquito bites:
• Wearing long sleeves, trousers.
• Cutting over grown glass around our houses

16. Chemoprophylaxis
• Mefloquinine 250mg weekly (up to 1 year) or doxycycline 100mg daily
(up to 3 month), to start 1 week before and continue till 4 weeks after
leaving the area.
• Indicated for travellers travel to endemic areas.

17. THE END
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