4. Indian scenario
Mortality most often due to P. falciparum
P. vivax (50-55%)
P. falciparum (48-52%)
P. malariae (small #, foothills of Orissa)
P. ovale (not found)
95% of pop. live in malaria risk areas
90% of malaria unstable (low incidence and
epidemics every 7-10 yrs)
17. Coma Scale for Children
Best Motor response
Verbal Response
Eye Movements
Localizes painful stimulus
Withdraws limb from pain
Non-specific or Absent
response
Appropriate Cry
2
Moan or Inappropriate cry
None
Directed
(e.g. follows mother’s face)
Not directed
Total
2
1
0
1
0
1
0
0-5
18. SEQUALE
Transient neurologic sequelae ataxia, hemiparesis, memory disturbance, visual
field defects, cognitive impairment, and behavioral
abnormalities
A postmalaria neurological syndrome
characterized by acute onset of
confusion, seizure, ataxia, myoclonus, tremor, and
aphasia
19. PROGNOSTIC FACTORS
the level of consciousness
presence of other organ dysfunction
Recurrent seizures,
decerebration,
retinal hemorrhage,
age < 3 years,
heavy parasitemia, (>20%),
lactic acidosis,
elevated CSF lactate
serum transaminase,
20. DIAGNOSIS
Demonstration of asexual form of P. falciparum in
peripheral blood smear, in thick and thin blood smear
films stained by Giemsa stain.
21. LIGHT MICROSCOPY
Thick blood film-
enhanced sensitivity , low levels of parasitemia
-Thin blood film.- identification of the parasite to the
species level
24. Recommendations
At least 3 smears 6 h apart should be examined.
before excluding cerebral malaria.
Parasitological confirmation of the diagnosis of
malaria provided by high-quality microscopy
or, where this is not available, by RDTs is
recommended for all suspected cases of malaria
25. OTHER DIAGNOSTIC TESTS
-DETECTION OF MALARIAL ANTIGENS
1.Pl Glutamate Dehyrogenase
2.Pl Falciparum HRP II- only in Falciparum
3. Pl LDH
- DIAGNOSIS USING FLUORESCENCE
MICROSCOPY
-Fluorescent dyes have an affinity for the nucleic acid in
the parasite nucleus (ACRIDINE ORANGE)
26. CSF EXAMINATION
-Necessary to exclude other causes of febrile
encephalopathy.
-CSF is generally normal in cerebral
malaria, however, mild pleocytosis (10–50 cells/mm3)
and protein rise up to 200 mg/dL may be seen.
27. CT and MRI are usually normal or show edema and
cortical or subcortical infarcts in watershed zone in
15%–20% patients.
EEG shows nonspecific abnormalities, such as diffuse
slowing, spike wave discharges, and burst suppression
pattern
28. TREATMENT
Neurologic emergency requiring urgent
intervention.
In endemic area, treatment should be started without
waiting for confirmation of the diagnosis
30. UNCOMPLICATED FALCIPARUM
MALARIA
ACT options now recommended for treatment of
uncomplicated falciparum malaria
artemether plus lumefantrine,
artesunate plus amodiaquine,
artesunate plus mefloquine,
artesunate plus sulfadoxine-pyrimethamine,
dihydroartemisinin plus piperaquine.
31. Artesunate plus sulfadoxine-pyrimethamine –
containing 50 mg of artesunate and tablets containing
500 mg of sulfadoxine and 25 mg of pyrimethamine
Therapeutic dose- artesunate given once a day for 3
days and a single administration of sulfadoxinepyrimethamine on day 1,
32.
33. Artemether plus lumefantrine:
standard tablets containing 20 mg of artemether and
120 mg of lumefantrine given twice a day for 3 days
Artesunate plus tetracycline or doxycycline or
clindamycin
These are reserved for very rare occasions of treatment
failures to the recommended ACTs
Any of these combinations should be given for 7 days.
34. Non-artemisinin based combination therapy
sulfadoxine-pyrimethamine plus chloroquine (SP+CQ)
or amodiaquine (SP+AQ)
- PROVEN TO BE INFERIOR
Artemisinins should not be used as
monotherapy, as this will promote resistance
35. P VIVAX AND MIXED INFECTION
P.vivax -Chloroquine for 3 days and Primaquine for 14
days
Chloroquine: 25 mg/kg body weight divided over three
days i.e. 10mg/kg on day 1, 10mg/kg on day 2 and
5mg/kg on day 3.
Treatment of mixed infections (P.vivax +
P.falciparum) cases:
course of ACT and Primaquine 0.25 mg per kg body
weight daily for 14 days.
37. Severe malaria should always be treated
with parenteral antimalarials
Drug of choice for cerebral malaria parenteral artemisinin derivatives or
quinine because of widespread resistance
to chloroquine.
38.
39.
40. QUININE
it should never be given as a push INTRAVENOUS
a continuous and uniform flow of IV quinine in
dextrose solution should be maintained over a
period of four hours
require monitoring of pulse, blood pressure, and
blood glucose.
IM injection carries the risk of necrosis at the injection
site and the injection is very painful.
41. Patients with cardiac disease and in older people, QTc
interval should be monitored
Quinine should be discontinued if QTc interval
exceeds 25% of the basal value.
42. ARTESUNATE
Artesunate has been reported to reduce mortality by
34.7% compared to quinine in a randomized
controlled trial in Asian adults.
Artemether and artesunate are advantageous because
of low toxicity, ease of administration
Artesunate, which is water soluble has the advantage
of i.v. or im. administration
Does not produce hypotension or hypoglycemia
43. Mefloquine is not preferred for cerebral
malaria because of neuropsychiatric
complication
Corticosteroids are not beneficial IN
cerebral malaria
BENEFICIAL IN POST MALARIA
SYNDROME
Phenobarbitone reduces the seizures, it
increases mortality specifically in children
44. SUPPORTIVE MANAGEMENT
Hydration by administration of fluids
Oral fluids should be given if the patient is conscious
and can swallow.
High fever should be reduced by the use of oral
paracetamol and tepid water sponging
46. MANGEMENT OF COMPLICATIONS
severe anaemia
renal failure
pulmonary oedema,
shock
spontaneous bleeding,
repeated generalized convulsions
acidemia or acidosis
47. MALARIA IN PREGNANCY
Pregnant women in the first trimester with
uncomplicated falciparum malaria should be treated
with quinine plus clindamycin for seven days
artemisinin derivatives in the second and third
trimesters
Primaquine and tetracyclines should not be used in
pregnancy
