Written by Dr.Md.Redwanul Huq (Masum)

Sunday, 15 January 2012 16:12

Definition:

Malaria is a parasitic infection caused by, Plasmodium vivax , P. falciparum, P. ovale and P. malariae .

History:

Travel history to endemic area(s) may be positive.

Symptoms of malaria:

Symptoms of malaria are-

•   Fever comes with chills and rigor and subsides with sweating, usually has cold, hot and sweating stages, comes on every alternate day in case of infection by P. vivax,P. falciparum or P. ovale and comes on every 3 rd day if the infection is by P. malariae
•   Headache
•   Malaise
•   Vomiting
•   Diarrhea
•   Yellow coloration of skin or mucosa
•   Symptoms of complications (if any)

Signs of malaria:

Signs of malaria are-

•   Fever
•   Anemia- may be present
•   Jaundice- may be positive
•   Hepatomegaly
•   Splenomegaly

Investigation:

•  TC, DC – may be normal or leucopenia with relative lymphocytosis
•  Hb % – normal or decreased
•  ESR – increased
•  PBF – Malarial parasites may be present
•  ICT for malaria (Antigen based test where Antibody is looked for)
•  IFAT, ELISA are also done sometimes
• To exclude Differential Diagnoses- Blood for C/S, CSF Study, Liver function tests.

Treatment for malaria:

1. Uncomplicated Malaria presumptive (UMP):

Definition:

•   Fever or history of fever over the last 48 hours
•   Absence of definite features of any other febrile illness
•   Living in or traveling to Endemic area(s)
•   PBF or Rapid Diagnostic Test (RDT) is not available

Treatment:

Day	Drug	Dose of drugs according to body weight
		30-39 kg	40-49 kg	50kg or more
1 st day	Tab.Chloroquine (150 mg base)	2 tab at a time	3 tab at a time	4 tab at a time
2 nd day	Tab.Chloroquine (150 mg base)	2 tab at a time	3 tab at a time	3 tab at a time
3 rd day	Tab.Chloroquine (150 mg base)	2 tab at a time	3 tab at a time	3 tab at a time

2. Uncomplicated Malaria confirmed (UMC):

Definition:

•   Fever or history of fever over the last 48 hours
•   Absence of definite features of any other febrile illness
•   Living in or traveling to Endemic area(s)
•   Diagnosis is confirmed by PBF or Rapid diagnostic test (RDT).

Treatment:

For P. vivax infection (Also for Chloroquine sensitive malaria):

Day	Drug	Dose of drugs according to body weight
		30-39 kg	40-49 kg	50kg or more
1 st day	Tab.Chloroquine (150 mg base)	2 tab at a time	3 tab at a time	4 tab at a time
2 nd day	Tab.Chloroquine (150 mg base)	2 tab at a time	3 tab at a time	3 tab at a time
3 rd day	Tab.Chloroquine (150 mg base)	2 tab at a time	3 tab at a time	3 tab at a time
4 th day	Tab. Primaquine (15 mg base)	1½ tab at a time	2 tab at a time	3 tab at a time

Then, Tab. Primaquine (15 mg base) – 1 tab daily for more 14 days.

OR,

1 st day – Tab. Chloroquine (150 mg base) – 4 tab at a time and after 6-8 hrs

Tab. Chloroquine (150 mg base) – 2 tab at a time

2 nd day – Tab. Chloroquine (150 mg base) – 2 tab at a time – 24 hrs after last intake

3 rd day – Tab. Chloroquine (150 mg base) – 2 tab at a time – 24 hrs after last intake

From 4 th day – Tab. Primaquine (15 mg base) – 1 tab / day – for 14 –  21 days.

For P. falciparum infection (Also for Chloroquine resistant malaria):

1 st line treatment:

Tab. Coartem (Artemethur 20mg + Lumefantrine 120mg) – 24 tablets in 6 divided dosages for adults (in 3 days) i.e. 4 tab 2 times daily for 3 days where on the 1 st day -4 tab should be taken stat & another 4 tab after 12 hours.

2 nd line treatment:

Day	Drug	Dose of drugs according to body weight			Additional Drug
		30-39 kg	40-49 kg	50 kg or more
1 st day	Tab. Quinine(300mg base)	1½ tab-tds	2 tab-tds	2 tab-tds	Tab. Tetracycline(500mg)-qdsOr,Tab. Doxycycline(100mg)-once daily
2 nd day	Tab. Quinine(300mg base)	1½ tab-tds	2 tab-tds	2 tab-tds	Tab. Tetracycline(500mg)-qdsOr,Tab. Doxycycline(100mg)-once daily
3 rd day	Tab. Quinine(300mg base)+Fansider (Sulfadoxin 500 mg + Pyrimethamine 25 mg)[Avoid if pregnancy]	1½ tab-tds+2 tab (single dose)	2 tab-tds+2½ tab (single dose)	2 tab-tds+3 tab (single dose)	Tab. Tetracycline(500mg)-qdsOr,Tab. Doxycycline(100mg)-once daily
4 th day	Tab. Quinine(300mg base)+Fansider (Sulfadoxin 500 mg + Pyrimethamine 25 mg)+Tab.Primquine(15 mg base)	1½ tab-tds+2 tab (single dose) +1½ tab (single dose)	2 tab-tds+2½ tab (single dose)+2 tab (single dose)	2 tab-tds+3 tab (single dose)+3 tab (single dose)	Tab. Tetracycline(500mg)-qdsOr,Tab. Doxycycline (100mg)-once daily
5 th day	Tab. Quinine(300mg base)	1½ tab-tds	2 tab-tds	2 tab-tds	Tab. Tetracycline(500mg)-qdsOr,Tab. Doxycycline(100mg)-once daily
6 th day	Tab. Quinine(300mg base)	1½ tab-tds	2 tab-tds	2 tab-tds	Tab. Tetracycline(500mg)-qdsOr,Tab. Doxycycline(100mg)-once daily
7 th day	Tab. Quinine(300mg base)	1½ tab-tds	2 tab-tds	2 tab-tds	Tab. Tetracycline(500mg)-qdsOr,Tab. Doxycycline(100mg)-once daily

3. Severe Malaria:

Definition:

Severe malaria includes-

1.   Fever or history of fever over the last 48 hours
2.   Presence of asexual form of P. falciparum in PBF or positive RDT
3.   Presence of one or more of the following features of severity:

• Confusion
• Abnormal behavior
• Convulsion
• Hypoglycemia
• Inability to stand or walk
• Moderate to severe vomiting
• Severe diarrhea
• Acute renal failure
• Acute pulmonary edema
• Severe anemia
• Jaundice
• Bleeding due to DIC
• Shock
• Unconsciousness.

Treatment for severe malaria:

Quinine HCl – IV at a dose of 20 mg /kg with 500 ml 5 % DA or DNS over 4 hours (at a rate of 30 drops/min). It is repeated at a dose of 10 mg /kg at an interval of 8-12 hours until the patient become conscious. After regaining consciousness Tab. Quinine (300mg base) is given for 7 days.

OR,

Artemether – IV/IM at a dose of 3.2 mg /kg, followed by at a dose of 1.6 mg /kg – 1 st day 12 hourly then once daily.

OR,

Arteseunate – IV/IM at a dose of 2.4 mg /kg, followed by at a dose of 1.2 mg /kg -1 st day 12 hourly then once daily.

Malaria Prophylaxis :

Duration:

Malaria prophylaxis should be started 1 week before going to endemic zone, continued during staying in that zone and till 4 weeks after returning from the zone.

Drug: Tab. Mefloquine 250mg – one tab / week.

Or

Cap. Doxycycline 100mg – once daily.

Black water fever:

Definition:

Black water fever is a clinical presentation of malaria (by P. falciparum) that occurs in a previously infected patient and is characterized by sudden intravascular hemolysis which is followed by development of fever and hemoglobinuria.

Precipitating factors:

Cold, sunlight, Quinine, pregnancy, parturition.

Susceptible cases:

Patients suffering from falciparum malaria are susceptible to develop Black water fever, especially those who have taken anti-malarial drugs irregularly or those who are non-immune persons and have taken irregular anti-malarial prophylaxis. Individuals with Glucose – 6 – phosphate dehydrogenase (G6PD) deficiency are also susceptible.

Symptoms of Black water fever:

1. High grade fever with chills and rigor
2. Passage of dark urine
3. Abdominal pain
4. Vomiting
5. Diarrhea
6. Symptoms of complications.

Signs of Black water fever:

1. Fever
2. Anemia
3. Jaundice
4. Signs of complications.

Complications:

1. Renal failure
2. Liver failure
3. Circulatory collapse.

Investigations:

In PBF- Malarial parasite (MP) is not found during attack.

Treatment:

General treatment:

1. Bed rest
2. Intravenous infusion
3. Hydrocortisone is given IV which is followed by oral prednisolone
4. Frusemide is used for diuresis
5. Dialysis should be given- if renal failure develops
6. Correction of anemia, blood transfusion if needed.

Specific treatment:

Tab. Chloroquine is the drug of choice.