Common Tropical Disease in Thailand

Dr.Sathaporn Kunnathum21 January 2010

The patient does not care about your science; what he wants to know is, can you cure him? 

~Martin H. Fischer

Dengue Infectiontransmitted by the bite of an Aedes mosquito

infected with any one of the four dengue viruses.

Clinical disease courseDengue feverDengue fever is usually a self-limiting

disease DHF/DSSDHF/DSS occurs mostly in endemic areas

Outcome of DHF/DSS improved with early diagnosis and treatment

Case definition for dengue feverAn acute febrilefebrile illness with 2 or more of

the following manifestations:-       -        Headache Headache-         Retro-orbital pain-         Retro-orbital pain-         Myalgia-         Myalgia-         Arthralgia-         Arthralgia-         Rash-         Rash-         Haemorrhagic manifestations-         Haemorrhagic manifestations-         Leucopenia-         Leucopenia    AND HAI / IgG ELISA antibody titre HAI / IgG ELISA antibody titre 1280 or 1280 or

positive IgM in late acute or convalescent positive IgM in late acute or convalescent serumserum

Case definition for

Dengue Haemorrhagic Fever (DHF) ALL 4 MUST BE PRESENTALL 4 MUST BE PRESENT::

1. Fever2. Haemorrhagic tendencies3. Thrombocytopenia (100 x 109 /L or less)4. Objective evidence of plasma leakage

caused by increased vascular permeability:  Elevated haematocrit (defined as 20% or more over baseline, Elevated haematocrit (defined as 20% or more over baseline,

or a similar drop after volume replacement therapy) or or a similar drop after volume replacement therapy) or     Low protein; or pleural effusion or ascitesLow protein; or pleural effusion or ascites

(WHO)(WHO)

Case definition for Dengue shock syndrome (DSS) 4 criteria for DHFPLUS signs of shock:1. rapid, weak pulserapid, weak pulse2. narrow pulse pressure (less than 2. narrow pulse pressure (less than

20mmHg)20mmHg)3. hypotension for age 3. hypotension for age 4. cold, clammy skin and restlessness4. cold, clammy skin and restlessness 

Treatment Fluid rehydrationRestAntipyretics Monitor BP, haematocrit, platelet count, RFT,

LFT, level of consciousness, signs of bleedingOxygen, sedation and blood product

transfusion as required

caused by a parasite called Plasmodium, which is transmitted via the bites of infected mosquitoes.

Anopheles spp.

ClassificationThere are 4 species:

plasmodium falciparum plasmodium vivax plasmodium ovale plasmodium malariae

Epidemiology

Pathogenesis

Symptoms and signsDepends on the type of malaria:

P. falciparum: The most dangerous type. Insidious onset. Malaise, headache, vomiting. Fever. Cough, diarrhea. Jaundice. Tender hepatosplenomegaly. Anemia develops rapidly.

Symptomology P.vivax and P.oval:

Fever: classically every 48 h. Rigors. Gradual hepatosplenomegaly. Anemia develops slowly. Relapse is common.

SymptomologyP.malariea:

Fever: every third day. Mild symptoms. Parasitaemia may persist for many years. Causes glomerulonephritis and nephrotic syndrome

in children.

Diagnosis Malaria should be suspected clinically!! Thick and thin blood films:

Thick film: are 20 times more sensitive than thin smears, but speciation may be more difficult.

Thin films: essential to confirm the diagnosis and to identify the species of the parasite. and In P.falciparum to quantify the parasite load.

Blood filmsP.falciparum P.malariea

DiagnosisP.vivax P.ovale

DiagnosisImmunochromatographic “dipstick” test for

P.falciparum should be used parallel with blood film

examination.

PreventionAvoid mosquito bites:

Wearing long sleeves, trousers.Nets.Repellent creams or sprays.

UNCOMPLICATED MALARIA

Uncomplicated malaria definition:

Fever and any of the following: Headache,Body and joint painsFeeling cold and sometimes shiveringLoss of appetite and sometimes

abdominal painsDiarrhoea, nausea and vomiting.Spleenomegaly

Uncomplicated malaria treatmentP. falciparum malariaThe treatment of uncomplicated P.

falciparum malaria is undertaken after diagnosis of malaria by light microscopy or Dipstick.

Patients with positive think-thick blood smears or dipstick for P. falciparum malaria is treated by blisters of Coartem® (artemether 20mg/lumefantrine 120mg). See Table 1 for details of prescription.

Table 1 : Dosage and administration Coartem (Artemether 20 mg/Lumefantrine 120 mg) for uncomplicated malaria falciparum

Age group Weight groupBlistercolor

(Day 1) (Day 2) (Day 3)

4 months to 5yrs

5 to 14 kg Yellow1 tb , 1 tb , 1 tb ,

1 tb 1 tb 1 tb

6 to 11y 15 to 24 kg Blue2 tb , 2 tb , 2 tb ,

2 tb 2 tb 2 tb

12 to 14y 25 to 34 kg Orange3 tb , 3 tb , 3 tb ,

3 tb 3 tb 3 tb

> 14y > 34 Green4 tb , 4 tb , 4 tb ,

4 tb 4 tb 4 tb

Source: Guideline for the treatment of malaria, WHO; 2006

Coartem® Dosage Schedule

Source: WHO, 2007

Important notes (1) 1. It is obligatory to give Coartem® to

patient whose dipstick test or blood slide is positive for P. falciparum and to the patient who has mixed infections P. falciparum and P .vivax.

2. Give the correct dosage of Coartem® from the appropriate blister according to the patient’s weight or age.

3. Children under 5 kg or below 4 months should not be given Coartem instead treat with the following regimen (see table 2).

Table 2. Dosage and administration Plasmodium falciparum for young infant

Age GroupWeight 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/TID for

4 days then 15-20 mg/kg TID for 4 days

Source: Malaria in Children, Department of tropical Pediatrics, Faculty of Tropical Medicine, Mahidol University.

** Preferably Artesunate/Artemether IM on day 1 if available *** When Artesunate/Artemether IM is unavailable, give oral Artesunate from day 1 to day 7* Treat the young infant with Quinine when oral Artesunate is not available

Important notes (2)4. In case parasitological diagnostic facilities are not

available paracetamol could be given to relieve pain and fever and referred to health facilities where parasitological diagnosis will be carried out.

5. Only in exceptional case when there is problem with thereferring patient in other health facility coartem® could be administered. (The health facility manager should write explanatory note why giving coartem® without parasitological diagnosis).

Important notes (3)6. Watch all patients swallowing the first dose

of coartem® and observe for 1 hour after the intake. In the event of vomiting within one hour of administration, a repeat dose should be taken.

7. Inform patient that, the coartem® tablets are in the blister and after breaking should be taken immediately, as after 24 hours coartem® tablets exposed to air totally inactivated and can not be used for treatment of malaria.

8. Each blister of coartem® has expiry date and should not be used after the expiry date.

Important notes (4)9. For small children, paracetamol and

coartem® can be crushed, diluted in water and then put either directly into the mouth using a syringe or given with a spoon.

10. Any patient who seeks re-treatment for malaria within 2 weeks of taking full dose of any other antimalarial should be treated with coartem®.

Uncomplicated malaria treatmentP. vivax malaria Resistance of P. vivax to chloroquine has

not been found in Timor-Leste and Chloroquine is the drug of choice

Chloroquine is safe and has few side effects. For the radical treatment of P. vivax in addition

to chloroquine, primaquine is recommended 0.5mg/kg per day for 14 days (primaquine should always be taken with food).

Chloroquine can be given to pregnant women and children.

Primaquine is not recommended for the children under one year and pregnant women.

• Details of treatment see table 4a.

Table 4a. Dosage and administration of Chloroquine and Primaquine for malaria vivax.

Age Group* Weight

group (Kg)

CHLOROQUINE(150 mg base) 10 mg/kg on the

first two days. 5 mg/kg on day 3

PRIMAQUINE(15 mg base) 0.5 mg/kg bw

Give for 3 daysStart concurrently with CQ and give daily for 14 daysDay 1 Day 2 Day 3

4 months up to 12 months

4 - <10 ½ ½ ¼ -

13 months up to 5 years

10 - <19 1 1 ½ ¼

6 - 7 years 19 - < 24 1½ 1½ 1 ½

8 - 11 years 24 - <35 2½ 2½ 1 ¾

12 - 14 years 35 - < 50 3 3 2 1½

15 + 50 or more 4 4 2 2

P. vivax malaria

Young infant less than 5kg or below 4 months should be treated with Chloroquine alone for three days consecutive (Table 4b).

Table 4b. Dosage and administration of Chloroquine for malaria vivax in young infant

Age Group

Weight group

Chloroquine

Day 1 Day 2 Day 3

0 - 4 months

<5 kg 10 mg/kg 5 mg/kg 5 mg/kg

P. falciparum and P. vivax (mixed infections)

The type of malaria where both infections occurs in patient requires treatment by

Coartem®.

Notes:Negative dipstick or thin-thick blood

smear:If the Pf dipstick is negative and the clinical signs are

typical for malaria, treat with Chloroquine (it could be a case of P. vivax infection).

If the Pf dipstick is negative and the clinical signs don’t suggest malaria, do not treat like malaria; look for another illness.

If the blood slide is negative, look for another illness. If symptoms persist, ask for another dipstick or blood slide.If dipstick and/or thin-thick blood smear are not

available: If there is no possibility of dipstick or slide results, treat the

patient based on the clinical signs and symptoms. Treat as if the patient has P. falciparum.

Follow-up of uncomplicated malaria:If symptoms persist after treatment with

coartem® or if the patient comes back before the 14th day after treatment.

Treatment failure within 14 days of receiving coartem® is extremely rare and is more likely to be an inadequate absorption of the drug(s) than resistance of the parasites. It is important to determine from the patient’s history whether he or she vomited during the previous treatment or did not complete the full course.

If patient is in health facility where microscope is available failure of treatment should be confirmed parasitologically and could be treated using the following regimen:

Follow-up of uncomplicated malaria:For adult:Quinine (10mg salt /kg bw three times a day) + doxycycline

(3.0mg/kg bw once a day) for 7 days. Do not give doxycycline with milk or iron, which will reduce its absorption.

If patient is in health facility where microscopy facility is not available patient should be referred to the facility where microscope is available. If refer is not possible treatment should be given Quinine + Doxycycline. Please refer to Table 5 for details of the prescription.

Doxycycline should not be given to pregnant or lactating woman, or child aged up to 8 years.

For pregnant or lactated woman or child less than 8 years:Quinine (10mg salt /kg bw three times a day) + clindamycin

(10mg/kg bw twice a day) for 7days. For small children, (quinine and clindamycin) crush tablets and mix with water and sugar.

Note:For high transmission areas where

parasitological confirmation is not available, children <5 yrs of age is recommended to be treated with anti malarial drugs when symptomatic (especially fever).

SEVERE MALARIA Severe or complicated malaria definition:

Fever and any of the following: Impaired consciousness Anxiety, palpitation and sweating Convulsions or fits with this fever Fast or difficult breathing Vomiting every feed / unable to feed Pale hands, tongue and inner parts of the eyelid Generalized body weakness Dehydration Jaundice Severe malnutrition Dark urine or no urine

Pre-referral treatment of severe malaria A patient who is non responsive should be

quickly assessed and managed. This includes assessment of the airway, breathing and circulation. The staff at the first level health facility should be able to maintain airway, provide assisted breathing and manage shock if required.

Pre-referral treatment for severe malaria the administration of Artesunate by the rectal route is recommended for all except pregnant women first trimester pregnancy. For the complete dosage and treatment.

Check blood sugar, if possible!

In case Artesunate suppository is not available IM quinine injection 20mg/kg bw should be given. The Quinine injection dosage should be split and injections given in the anterior part of the thigh.

In case Artesunate suppository is not available, give also Quinine for children with severe malaria.

Confirmed diagnosis of severe malaria: All clinically suspected severe malaria

cases require laboratory examination and confirmation.

Only in case where laboratory confirmation is not possible start treatment immediately. Parasitological confirmation is done by thin-thick blood smear microscopy examination or by dipstick (Rapid Diagnostic Test [RDT]).

Differential diagnosis for complicated malariaConsider other illnesses, such as:Measles, meningitis, tonsillitis, dengue,

otitis media (ear infection), influenza, pneumonia, typhoid fever, tuberculosis, hypoglycemia.

Specific severe malaria treatment Artesunate (60 mg): 2.4 mg/kg body weight

(bw) IV or IM on admission (time=0), followed by 2.4 mg/kg at 12 and 24 hours, followed by once daily for seven days. Once the patient can tolerate oral therapy, treatment should be switched to a complete dosage of coartem® for three days as recommended in the national treatment guidelines for uncomplicated malaria .The congenital malaria is also treated with Artesunate, where 2.4 mg/kg is initially given through IV, followed by 1.2 mg/kg at 12 and 24 hr then every 24 hr for 3 -5 days.

Specific severe malaria treatmentArtemether (80mg for adult and 40 mg for

children and the newborn): 3.2 mg/kg bw IM on the first day followed by 1.6 mg/kg bw daily for seven days. Once the patient can tolerate oral therapy, treatment should be switched to a complete dosage of coartem®.

Arteether (150 mg): 3.2 mg/kg bw IM on the first day, followed by 1.6 mg/kg bw for the next 4 days. Once the patient can tolerate oral therapy, may switch to a complete dosage of coartem®.

If Coartem® is not available, quinine should be administered in combination with tetracycline or doxycycline or clindamycin, to complete the seven-day treatment, except for pregnant women and children under eight years of age for whom tetracycline/doxycycline is contraindicated.

QuinineLoading dose: Quinine dihydrochloride 20

mg salt/ kg bw diluted in 10 ml/kg bw of 5% dextrose or dextrose saline administered by IV infusion over a period of four hours for both adult and children. In severe Childhood falciparum malaria, if patient received quinine or quinidine or mefloquine in 48 hrs before arrival, give 10 mg/kg over 2 hours.

QuinineMaintenance dose: Quinine dihydrochloride 10 mg

salt/ kg body weight diluted in 10 ml/kg body weight of 5% dextrose or dextrose saline administered by IV infusion. In adults, the maintenance dose is infused over a period of four hours and repeated every eight hours. Similarly in children including congenital malaria, it is infused over a period of two hours and repeated every eight hours (calculated from the beginning of the previous infusion) until the patient can swallow. To complete the seven-day to eight-day treatment in children, give Quinine sulfate 10 mg/kg per oral three times in a day. Increase the dosage of Quinine sulfate to 15-20 mg/kg after 4 days or add tetracycline 5 mg/kg twice a day for children above 7 years.

NotesArtemisinin derivatives are safe, effective, have a

wider therapeutic window, can be administered intramuscularly and should be considered a safer alternative to quinine.

A loading dose of quinine should not be given (1) if the patient has received or suspected to have received quinine, quinidine or mefloquine within the preceding 12 hours, and (2) facilities for controlled rate of flow of quinine infusion are not available. In order to improve treatment outcome of quinine add a course of oral tetracycline 4 mg/kg bw 4 times daily or doxycycline 3 mg/kg bw once daily except for children under 8 years of age and pregnant women, or clindamycin 10 mg/kg bw twice daily for 3-7 days.

If there is no clinical improvement after 48 hours of parenteral therapy, the maintenance dose of parenteral quinine should be reduced by one-third to a half (i.e., 5-7 mg/kg bw quinine dihydrochloride). .

LeptospirosisCause : Leptospira interrogans

1.Source of infection: rat,pig

EPIDEMIOLOGY

clinical features: three symptoms, three signs, internal organ damage, seguelae of eyes and nerve system

PATHOGENESIS

leptospira

skin,mucosaInitial stage leptospiremia toxic symptoms (1~3days) three symptoms: fever,myalgia,fatigue; three signs: conjunctival suffussion; muscle tenderness; enlargement of lymphonodes;

PATHOGENESIS severe toxic symptoms lesion of organs: influenza form pneumorrhagic formmiddle stage icterohemorrhagic form(3~10d) meningoencephalitis renal failure form.

PATHOGENESIS

immunopathological reaction after fever; sequelae of eyes; reactive meningitis; cerebro arteritis obliterans.

convalescent stage

PATHOLOGY1. basic pathological change is infective,toxic injured of systemic capillaries; 2. severe:lung,liver,kidneys,brain. exudation,hemorrhage, edema or necrosis.

InvestigationCBCBUN/Cr , ElyteLFTCPKUACXRSerologyLP

Treatment1. Supportive treatment2. medication - Pen G 1.6 mu iv q 6 hr - Doxycycline (100) 1x2 o pc - Ceftriaxone 2 g iv ODfor 7 days

MelioidosisCause : Burkholderia pseudomallei

Center for Food Security and Public Health Iowa State University 2005

OrganismBurkholderia pseudomallei

Aerobic, gram-negative motile bacillus

Found in water and moist soilOpportunistic pathogenProduces exotoxinsCan survive in phagocytic cells

Latent infections common

Worldwide distribution of melioidosisWorldwide distribution of melioidosis

Cheng AC and Currie BJ. Clin Microbiol Rev 2005; 18:383-416.Cheng AC and Currie BJ. Clin Microbiol Rev 2005; 18:383-416.

Center for Food Security and Public Health Iowa State University 2005

TransmissionWound infection

Contact with contaminated soil or waterIngestion

Contaminated waterInhalation

Dust from contaminated soilRarely

Person-to-personAnimal-to-person

Disease of rice farmers Endemic in tropics and

subtropicsSoutheast Asia, Australia, The

Middle East, India, China, Caribbean

Rick factorThalassemiaDiabetes CirrhosisKidney disease Cancer Immune suppressed Immunocompromise SLE

Center for Food Security and Public Health Iowa State University 2005

Human DiseaseIncubation period: 2 days to yearsLatent infection Most infections asymptomaticClinical forms

Acute pulmonary infection Most common

Focal infectionSepticemiaNeurological (rare)

InvestigationCBCBUN/CrLFTCPKUACXRSerologyLPH/CImagine study

Treatment1. Supportive treatment2. Specific treatment 2 weeks Ceftazidime 2g iv q 8 hr +- Bactrim

2 amp iv q 8 hr then Bactrim 2x3 o pc + doxycycline 1x2 o

pc until 20 weeks

Parasite

TreatmentAlbendazole(200) 2 x 1 O pc 5 daysIvermectin 0.2 mg/kg single dose

Praziquantel 40 mg/kg single dose

Body and soul cannot be separated for purposes of treatment, for they are one and indivisible.  Sick minds must be healed as well as sick bodies. 

~C. Jeff Miller

Thank you for your attention