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
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
3. More commonly, the patient presents with
a combination of the following symptoms
Nausea and vomiting
4. SEVERE COMPLICATED MALARIA
Alteration in the level of consciousness (ranging from drowsiness to
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)
Abnormal bleeding (Disseminated Intravascular coagulopathy)
5. SEVERE COMPLICATED MALARIA
Haemoglobinuria (black water fever)
Acute renal failure - presenting as oliguria or anuria
Severe anaemia (Haemoglobin < 5g/dl or Haematocrit <
Hypoglycaemia (blood glucose level < 2.2.mmol/l) defined
as the detection of P. falciparum in the peripheral blood
6. INVESTIGATIONS AND LABS
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)
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
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
• 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).
Artesunate or *Quinine
0 - 4
** IM first dose
mg/kg or IM
day 2 to day 7
for 4 days
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,
• 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
• •Avoid mosquito bites:
• Wearing long sleeves, trousers.
• Avoid mosquito bites:
• Wearing long sleeves, trousers.
• Cutting over grown glass around our houses
• 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.