Management of severe falciparum malaria Dr SK Mishra,MD Ispat General Hospit al, Rourkela 769005 India.

Management ofsevere falciparum malaria

Dr SK Mishra,MDIspat General Hospital,

Rourkela 769005India

Falciparum malaria is a potentially fatal disease

Successful treatment completely cures without disability

Early diagnosis and prompt treatment prevents fatal complications 2

Severe malaria 1. Cerebral malaria2. Acute renal failure 3. ARDS4. Severe anaemia (Hb < 5g%)5. DIC6. Haemoglobinuria7. Hypotension, Shock8. Hyperparasitemia9. Repeated seizures10. Hyperpyrexia11. Haemolysis (Sr bil. >3 mg%)

Diagnosis of malaria

1. History and clinical features * locality , travel history * fever * spleno-hepatomegaly * presence of complications

2. Laboratory diagnosis 3

* Drug history* Anti malarials* Blood transfusionHistory of - haemoglobinopathy - diabetes - alcoholism/ jaundice

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Specifically ask / look for - fever with duration - headache

- vomiting, diarrhoea - urine output and colour - cough / dyspnoea/ bleeding - altered sensorium / seizures - pregnancy 5

Clinical examination Pallor, icterus bleeding signs early signs of pulm oedema consolidation arrhythmia hepatosplenomegaly uterus 6

CNS ExaminationSensorium /coma score- Glasgow coma score- Blantyre coma score- decerebrationPupils, Fundus examinationNeck stiffnessPlantar reflex 7

Laboratory diagnosis

Microscopy Immunological tests Antigen capture tests Antibody detection tests QBC test DNA probe PCR 8

Microscopygold standard for diagnosisthick smear: rapid diagnosisthin : species identification

other advantage- platelets, anaemia, toxic picture

If negative : repeat blood test 6 hourly for 6 times

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Why parasites are not detected at times in peripheral smear ?a. sequestration in deep vascular bedb. partially treated patientsc. prophylactic antimalarial treatmentd. inexperienced microscopiste. poor quality staining

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Antigen capture tests* Pf-ICT test * Parasight-F test/ Malacheck etcPrinciple: dipstick antigen capture assay employs a monoclonal antibody detecting the Pf.HRP-2 antigen in the bloodRapid, simple, sensitive testSpecies specificity 11

Antibody detection test- RIA - ELISAantibody persists for a long time so not helpful in acute infection

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QBC testSpinning blood in a specialised capillary tubes in which parasite DNA is stained with acridine orange.Detected by ultraviolet microscopeSensitive and specific (?) inExperienced hands

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PCR testSensitiveCan identify different speciesTakes 48- 72 hoursExpensiveAvailable in selected places only

DNA Probes 14

Cerebral malariaComa scoringExclude other causes of coma

1. ABC of coma care2. Prompt institution of antimalarials3. Treatment of hyperpyrexia4. Management of other complications5. Treatment of associated infections 17

Antimalarial therapy

Parenteral therapy is a must asrapid parasitecidal action is warrantedMainstay of therapy is Quinine- Loading dose or not ?- IV is the route of choice - Donot reduce the dose in first 48 hours of quinine therapy- 20% renal and 80% hepatic clearance

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Quinine therapy

10 mg/ kg body weight over 4 hours every 8 hourly in DNS or dextrose.

If therapy has to continue beyond 48 hours reduce dose to 2/3rd.

T 1/2 healthy subjects - 11 hours uncomplicated patients 16 hours cerebral malaria - 18 hours

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Side effects:Minor: cinchonism, tinnitus deafness, vertigo, vomitingdoes not require stoppage of quinine treatment.

Severe: hypoglycemia, DIC,haemolysis, arrhythmia, thrombocytopenia etc. These complications are rare.

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Artemisinine compounds Rapid schizonticidal drugArteether (E-mal) inj150 mg deep im od x 3 daysArtemether (Larither)Inj 80 mg im bid x 3 daysor Inj. 80 mg bid first day then od x 4 daysArtesunate (falcigo)Unstable, to be prepared before administration 2.4 mg/kg first dosem then 1.2 mg 12 hr then daily for 3-4 days 21

COMMON ERRORS INMANAGEMENT OFSEVERE MALARIA 1.Failure to diagnose associated complications such as bacterialinfections, eclampsia, Gram negative septicemia etc.2. Missed hypoglycaemia3. Misjudgement of severity

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4.Errors of fluid and electrolytic replacement5.Errors in anti-malarial chemotherapy6. Delay in starting treatment Unjustified withholding of antimalarial drug for the fear of toxicity e.g. Quinine in pregnant women, in hypoglycaemia-Inadequate dosage administration-Failure to control the rate of IV infusion 23

7. Delay in considering obstetrics intervention pregnant women suffering from malaria

8.Missed / late diagnosis of ARDS, acute pulmonary oedema

9 Use of inappropriate ancillary therapies e.g. steroids, .

10. Delay in starting dialysis24

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