Malaria Pp t

8/12/2019 Malaria Pp t

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MALARIAMALARIA

Safana Mushtaq, MDSafana Mushtaq, MD


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OBJECTIVESOBJECTIVES

Geographical distributionGeographical distribution

Malaria in US & World wideMalaria in US & World wide

Life Cycle of Malarial parasiteLife Cycle of Malarial parasite

Types of plasmodiumTypes of plasmodium

DiagnosisDiagnosis

Clinical featureClinical feature

Treatment & preventionTreatment & prevention


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Geographical DistributionGeographical Distribution


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Malaria WorldwideMalaria Worldwide

41% of worlds population live in areas where41% of worlds population live in areas where

malaria is transmittedmalaria is transmitted There are 300There are 300--500 million new cases of malaria500 million new cases of malaria

every year.every year.

An estimated 700,000An estimated 700,000--2.7 million persons die of2.7 million persons die ofMalaria every year, 75% of them are African childrenMalaria every year, 75% of them are African children

In areas of Africa with high transmission there areIn areas of Africa with high transmission there are

about 2700 deaths per day, 2 deaths per minute.about 2700 deaths per day, 2 deaths per minute. Malaria is fourth leading cause of death.Malaria is fourth leading cause of death.


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Mortality andMortality and ChloroquineChloroquine resistanceresistance

0

5

10

15

20

25

1900 1920 1940 1960 1980 1997

Sub-Saharan Africa Outside Sub-Saharan Africa

resistance enters Africa

Chloroquine introduced


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100.010,596Total

101,022Other causes

3305Injuries7

3321HIV/AIDS6

4395Measles5

8853Malaria4

171,762Diarrheal diseases3

192,027Acute respiratory infections2

373,910Neonatal causes1

% of alldeaths

Numbers(x1000/year)

CauseRank

Leading Causes of Death in Children UnderFive, for 2000-03 (WHO)


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Malaria in the United StatesMalaria in the United States

Malaria eradicated from USMalaria eradicated from US

Over 1300 cases of malaria were reported in USOver 1300 cases of malaria were reported in USevery yearevery year

Out of these case, nearly all are imported , InOut of these case, nearly all are imported , In

2002 out 13370 cases expect 5 cases all were2002 out 13370 cases expect 5 cases all wereimportedimported

Constant risk of reintroduction of malaria in USConstant risk of reintroduction of malaria in US

Transfusion related malariaTransfusion related malaria


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PlasmodiumPlasmodium -- life cyclelife cycle

Malaria transmitted by female Anopheles. OverMalaria transmitted by female Anopheles. Over

60 types60 types Apicomplexa group of protozoa, haveApicomplexa group of protozoa, have

specialized complex of apical organellesspecialized complex of apical organelles

involved in host cell invasion.involved in host cell invasion. Four Plasmodium species cause humanFour Plasmodium species cause human

Malaria:Malaria: P.vivaxP.vivax,, P.ovaleP.ovale,, P.malariaeP.malariae,,

P.falciparumP.falciparum


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Life Cycle..contLife Cycle..cont

Schizogony, occurs in human, intermediate host,Schizogony, occurs in human, intermediate host,

haploid replication.haploid replication.exoexo--erythrocytic stageerythrocytic stage

erythrocytic stageerythrocytic stage

Sporogony, occurs in mosquito gut, diploidSporogony, occurs in mosquito gut, diploid

zygoteszygotes


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Life cycleLife cycle


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Life cycle contLife cycle cont

ExoExo--erythrocytic Stage (liver)erythrocytic Stage (liver)

Sporozites invades and replicatesSporozites invades and replicates

All P.falciparum and P.malariae complete in 1All P.falciparum and P.malariae complete in 1--22

weeks.weeks.

P.Vivax and P.ovale may persist in liver, relapseP.Vivax and P.ovale may persist in liver, relapse

Erythrocytic Stage (RBC)Erythrocytic Stage (RBC)

Gametocyte FormationGametocyte Formation


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Clinical featuresClinical features

The classical attack lasts 6The classical attack lasts 6--10 hours.10 hours.

a cold stage (sensation of cold, shivering)a cold stage (sensation of cold, shivering)

a hot stage (fever, headaches, vomiting;a hot stage (fever, headaches, vomiting;

seizures in young children) , fever up to 104 Fseizures in young children) , fever up to 104 F

and finally a sweating stage (sweats, return toand finally a sweating stage (sweats, return to

normal temperature, tiredness)normal temperature, tiredness)

Paroxysms coincideParoxysms coincide synchronussynchronus rupturerupture

schizontschizont

Elevated TNFElevated TNF--alphaalpha


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Clinical featurescontClinical featurescont

Tertian Malaria , where paroxysms of malaria isTertian Malaria , where paroxysms of malaria is

repeated after 48 hrs or fever occurs every thirdrepeated after 48 hrs or fever occurs every thirdday. It is feature of P.falciparum, P.ovale andday. It is feature of P.falciparum, P.ovale and

P.vivaxP.vivax

Quartan Malaria , where paroxysms occurs afterQuartan Malaria , where paroxysms occurs afterevery 72 hour or fever occurs every fourth day. Itevery 72 hour or fever occurs every fourth day. It

is seen in P.malariaeis seen in P.malariae


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Severe MalariaSevere Malaria Pathogenesis : ability of parasite to sequester inPathogenesis : ability of parasite to sequester in

deep venous microvasculature through processdeep venous microvasculature through process

of cytoadherence.of cytoadherence.

Cerebral malariaCerebral malaria

Severe AnemiaSevere Anemia HemoglobinuriaHemoglobinuria

Pulmonary Edema/ARDSPulmonary Edema/ARDS

Coagulation Abnormalities andCoagulation Abnormalities andThrombocytopeniaThrombocytopenia

Cardiovascular collapse and shockCardiovascular collapse and shock


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Severe MalariacontSevere Malariacont

Nephrotic syndrome , seen inNephrotic syndrome , seen in P.malariaeP.malariae, young, young

children pronechildren prone Hyperparasitemia :>5% RBC infectedHyperparasitemia :>5% RBC infected

Metabolic acidosisMetabolic acidosis

Hypoglycemia : esp. in pregnant females even inHypoglycemia : esp. in pregnant females even in

uncomplicated malaria , after treatment withuncomplicated malaria , after treatment with

QuinineQuinine

Hyperactive malarial spleenomegalyHyperactive malarial spleenomegaly


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DiagnosisDiagnosis

Malaria must be recognized promptly in order toMalaria must be recognized promptly in order to

treat the patient in time and to prevent furthertreat the patient in time and to prevent furtherspread of infection in the communityspread of infection in the community

Malaria considered a potential medicalMalaria considered a potential medical

emergency. Delay in diagnosis and treatment isemergency. Delay in diagnosis and treatment isa leading cause of death in malaria patients ina leading cause of death in malaria patients in

the United States.the United States.

Suspect clinically, confirm with labsSuspect clinically, confirm with labs


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DiagnosiscontDiagnosiscont

History and Physical examHistory and Physical exam

Microscopic, Thin and Thick Blood filmsMicroscopic, Thin and Thick Blood films

Serology, rapid diagnostic tests( antigenSerology, rapid diagnostic tests( antigen

detection)detection)

ParsSight F, and OptiMalParsSight F, and OptiMal

Serology, antibody detection, indirect fluorescentSerology, antibody detection, indirect fluorescent

antibody, enzyme immunoassayantibody, enzyme immunoassay


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DiagnosisDiagnosisThick and Thin Blood SmearsThick and Thin Blood Smears

Light microscopy of Giemsa stained blood filmsLight microscopy of Giemsa stained blood films

Should be prepared and read immediately byShould be prepared and read immediately byexperienced personnelexperienced personnel

Thick smears , detect parasiteThick smears , detect parasite

Thin smears , for speciesThin smears , for species


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Diagnosis.contDiagnosis.contRapid Diagnostic testRapid Diagnostic test

ParaSight F and ICT Malaria PFParaSight F and ICT Malaria PF

Helpful , no expert microscopyHelpful , no expert microscopy

It depends on detection of P.falciparum histidineIt depends on detection of P.falciparum histidine--

rich protein 2 (HRPrich protein 2 (HRP--2)2)

Sensitivity is 77% to 100%Sensitivity is 77% to 100%

Specificity 83% to 100%Specificity 83% to 100%

LimitationsLimitations


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DiagnosisDiagnosisRapid Diagnostic TestRapid Diagnostic Test

OptiMal testOptiMal test

Detects plasmodium lactate dehydrogenaseDetects plasmodium lactate dehydrogenase(pLDH)(pLDH)

Sensitivity similar to ParaSight FSensitivity similar to ParaSight F

Advantage for all speciesAdvantage for all species

Therapeutic responseTherapeutic response


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Plasmodium FalciparumPlasmodium Falciparum

P. falciparum:P. falciparum:

trophozoites are smalltrophozoites are small

rings with single orrings with single or

double smalldouble small

chromatin dots, andchromatin dots, and

regular cytoplasm.regular cytoplasm.


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Plasmodium FalciparumPlasmodium Falciparum

Thin Smear, GiemsaThin Smear, Giemsa

MatureMature trophozoitetrophozoite

Thin Smear,Thin Smear, GiemsaGiemsa

TrophozoiteTrophozoite


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Plasmodium FalciparumPlasmodium Falciparum Thin Smear, GiemsaThin Smear, Giemsa

P.falciparum:P.falciparum:micromicro-- andand

macrogametocytesmacrogametocytes

crescenticcrescentic, cigar, cigar-- or bananaor banana--

like shape.like shape.

GametocyteGametocyte

QuantitaveQuantitave buffybuffy coatcoat

techniquetechnique


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Plasmodium MalariaePlasmodium Malariae

P.P. malariaemalariae,,

trophozoitestrophozoites Band shapeBand shape


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Plasmodium MalariaePlasmodium Malariae Thin Smear, Giemsa stain

Schizont Rosettes

Central pigment

Thin Smear,Thin Smear, GiemsaGiemsa

P.P. ovaleovale, ring, ring fornforn

Presence of dots or clefts onPresence of dots or clefts on

infected RBC are diagnostic oninfected RBC are diagnostic on

OvaleOvale speciesspecies


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Plasmodium ovalePlasmodium ovale

P.ovale, Giemsa StainP.ovale, Giemsa Stain

TrophozoiteTrophozoite All stages are seen inAll stages are seen in

blood filmsblood films

Prominent ShuffnersProminent Shuffners

dotsdots


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Plasmodium ovalePlasmodium ovale

SchizontSchizont

Enlarged RBCEnlarged RBC

OvalisedOvalised RBCRBC

P.ovaleP.ovale

GametocyteGametocyte


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Prevention and TreatmentPrevention and Treatment Prevention is based on followingPrevention is based on following

Evaluating risk of exposure to infectionEvaluating risk of exposure to infection

Preventing mosquito bitesPreventing mosquito bites ChemoprophylaxisChemoprophylaxis

Advice to seek medical care if malaria likeAdvice to seek medical care if malaria like

symptoms occursymptoms occur Presumptive treatment of malariaPresumptive treatment of malaria

Risk of ExposureRisk of Exposure

may be difficult to determine since it varies bymay be difficult to determine since it varies byclimate, rainy season, altitude, degree of mosquitoclimate, rainy season, altitude, degree of mosquitocontrol in rural versus urban areas, nature of visitcontrol in rural versus urban areas, nature of visit

adventure vs. business tripadventure vs. business trip


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Prevention..contPrevention..cont

Preventing mosquito bites is importantPreventing mosquito bites is important

Preventive measures when out door betweenPreventive measures when out door betweendusk and dawndusk and dawn

Clothing should cover most of bodyClothing should cover most of body

Mosquito repellents: deet ( N,NMosquito repellents: deet ( N,N--diethyldiethyl--33--methylmethylbenzamide) should be applied to exposed areasbenzamide) should be applied to exposed areasq 3q 3--4 hours,4 hours,

Living quarters be air conditioned or wellLiving quarters be air conditioned or wellscreenedscreened

Mosquito nets ,Mosquito nets , premethrinpremethrin


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Chemoprophylaxis

Less 8 yrs

pregnancy

100 mg q dayDoxycycline

Pregnancycategory C

250/100 mg q day

1-2 days before and continue 7

days after leaving area

Atovaquoneplus proguanil

Cardiacconduction

Psychiatric dis

250 q week1-2 wks before travel

4 wks after leaving area

Mefloquine

retinopathy500 mg q weekly

1-2 weeks before travel,

continue 4 weeks after leavingmalarious area

Chloroquine

Phosphate

precautionAdult doseDrug


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TreatmentTreatment

QuinidineQuinidine gluconategluconate IV,IV,

exchange transfusion if >15%exchange transfusion if >15%Complicated/Severe P.Complicated/Severe P.

FalciparumFalciparum

Quinine Sulfate +Quinine Sulfate + doxycyclinedoxycycline

oror atovaquoneatovaquone ++ proguanilproguanilUncomplicated P.Uncomplicated P. FalciparumFalciparum,,

chloroquinechloroquine resistantresistant

Chloroquine + PRIMAQUINE

G6PD screen

P. Ovale and P. Vivax

ChloroquineUncomplicated, P. Falciparumchloroquine sensitive

DrugType of Malaria


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Final CommentFinal Comment Malaria is mainly a disease of tropical and subtropicalMalaria is mainly a disease of tropical and subtropical

areas.areas.

There is constant risk of reintroduction of malaria inThere is constant risk of reintroduction of malaria inUnited States because of presence of AnophelesUnited States because of presence of Anopheles

Travelers should be given preTravelers should be given pre--travel advice andtravel advice and

chemoprophylaxis before departure tochemoprophylaxis before departure to malariousmalarious areaarea Since Chemoprophylaxis is not 100% effective measureSince Chemoprophylaxis is not 100% effective measure

should be taken to prevent mosquito bitesshould be taken to prevent mosquito bites

Detailed travel history and immigration history whenDetailed travel history and immigration history when

evaluating unexplained fever and considering malaria asevaluating unexplained fever and considering malaria asaa differntialdifferntial..

Fever before 8 days after reaching a endemic area isFever before 8 days after reaching a endemic area isunlikely to be malariaunlikely to be malaria


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Final CommentcontFinal Commentcont

Efforts should be made on part of WHO withEfforts should be made on part of WHO with

malaria endemic countries to eradicate malaria,malaria endemic countries to eradicate malaria,which is not just a killer but holds back humanwhich is not just a killer but holds back human

and economic developmentand economic development

DDT : second chanceDDT : second chance

Malarial Vaccine, more funding and researchMalarial Vaccine, more funding and research

Malaria Pp t

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