MALARIA

DEF:

Malaria is a febrile illness caused from the bite of an infected female anopheles mosquito from one or more of the four species.(P.falciprum- P.vivax- P. ovaleP.malarie)

PATHOLOGY
Infected RBCs rupture causing haemolytic anaemiah and deposition of pigment in reticuloendothelial cells.The infected RBCs may sludge and stick in organs interfering with circulation and induce infection.P. falciprum is assosiated with heavies degree of paracytaemia and is the most lethal. * SCA &G6PD def are assosiated with some protectiction againest lethal malaria.

According to :
# Clinical presentation # Laboratory findig # Treatment.

MALARIA is devided into: 1. Uncomplicated malaria. 2. Severe malaria .

UNCOMPLICATED MALARIA
Case definition:
Suspected: The child present with fever- headache- ache &pain.In young children may be irritable- refuse eating- there may be vomiting. Confirm: By present of asexual form(trophozoit)in thick or thin blood film.

IMCI:
Any febrile child (by history&examination)should be manage as having malaria after excluding of other causes&present of trophozoit in the the blood. children less than 5.

Laboratory diagnosis of malaria

1.microscopic diagnosis of malaria by thick blood film gimsa stain is required.
It show us:

1.present of infection 2.stage of parasite 3.parasite count

In Sudan 90% is due to P.falciprum.

How count for the parasite?

Under the microscope if you see:

1-100paracite/100 field + 11-100paracite/100field ++ 1-10paracite/1field +++ 11-100/1field ++++

Laboratory diagnosis of malaria

2.Rapid diagnostic test. ICT: Should be considered in relation to intensity of transmission

Treatment of un complicated malaria

*First line:
1st line treatment in sudan is Artesunate+sulfadoxine pyrimethamine(inform of tablet)

Artisunate (AS) is available in sudan for children as

50mg.side effect are not common besidetransient rise in transaminase& transient reduction inreticulocyte count has been reported.

Treatment of uncomplicatd malaria

Sulfadoxine-pyrimthemine(as):is afixed dose
combination of two anti folate is available in sudan in form of tablet(500mg sulfadoxine+25mg pyrimethamine). Side effect: Are revresable GITdisturbance &visual disterbance .cutaneous reactions .anaroxia.

FIRST LINE REGIMEN

Age( Wt(k year) g) Day Day3 2As As(50 Sp(500 Sp(50 (50 mg +25mg )tabs mg tab) tab) tab) >10 2/1 2/1 2/1 2/1 1 1 1 1 Day 1

>1

1->7 ->10 20 7-13 _20 40 14+ 40+

2
3

2
4

2
4

2
4

*second line treatment: Artemether-lumefatrine it is a highly effective anti malarial treatment. Each tablet contains a synthetic derivative of artimisinin(20mg);and lumefantrine (120mg) it has a high clinical &parasitological cure rate. Side effect are: Dizziness, fatigue,anoxia,nausia, vomiting,abdominal pain,palpitation,mayalgia,arthalagia,headac he skin rash.

Second line regimen

Age( Wt( yrs) kg) Day1 Day2 Day3 Tota lno. Of tab
eve

initiall y

after8 hour

mor eve mor

>1 >10 1->3 -10 14 3->8 -15 24 8-10 -25 34 11+ 35+ 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

6 12 18

24

Third line treatment

Quinine:found as Q Dihydrochloride,Q hydrochloride,Q sulphate orally should be used as a third line drug in case of no response to Artemetherlumefantrine.
Oral quinine is used 10mg\kgbody weight 8 hourly for 7 days. IM injection of quinine for those with reapeted vomitting.

Third line regimem

Age(yrs) Wt(kg) Number of tablet\dose (300)mg 1\4
1\2

1> 1-4

>10 10-18

5-7
8-10 11-15 <15

19-24
25-35 36-50 <50

1
1 1\4 1 1\2 2

SEVERE MALARIA
Case definition: Severe malaria is define as malaria due to P.falciprum infection that is suffieciently serious to be an immediate threat to life . Its amedical emergency which required hospitalization.

Clinical manifistation
1. Fever. 2.imparired level of consciousness 3.respiratory distress. 4.repetitive convulsion 5.ciculatory collapse. 6. Abnormal bleeding. 7. jundice

How to manage a child with severe malaria

(1)Immediate &emergency measures. (2)look &deal with evidence of complication. (3)monitoring&assesment of the child condition.

Immediate measures
1.Start resuscitation particulary patent airway. 2.Establish IV line. 3.Make a thick blood film for immediate parasite count.ICTmay be useful in certain condition. 4.Classify the degree of dehydration. 5.Control the fever by oral and rectal paracetamol. 6.Control convulsion 7.Detect &treat hypoglycaemia. 8.Start Quinine IV or artemether IM.

Evidence of complication
1)shock, algid malaria. 2)consider the need of blood transfusion. 3)metabolic acidosis. 4)spontaneous bleeding &coagulapathy. 5)acute renal failure. 6)malarial hemoglobinuria(black-water fever). 7)cerebral oedema. 8)exclude common infections.

Monitoring the child with sever malaria

1- level of consciousness: by Glasgco or blantyre coma scale. 2-Fluid input/out put. 3-Vital sing. 4-Level of parasitaemia.

Specific management
Quinine:is the preferable drug and should be given initially
byIV infusion, in 50% glucose.The dose is 10mg salt\kg body wt adminisrered 8 hourly for 7 days.

If IV Quinine is not possible:

IM Quinine can be given diluted with normal saline or distilled water to a concentration of 60mg\ml into both anterior upper thigh.

Artemether:found as injection.The dose for

childrenis1.6mg\kgtwice in the first day(12hr apart),followed by 1.6mg\kg daily for 6 days.

Dosage schedules for intramuscular quinine

age >4mon 4-11mon 1-2yr 3-4yr 5-7yr 8-10yr 11-13yr Wt (Q) INJ (kg) ml 5-6 7-10 11-14 15-18 19-24 25-35 36-50 0.2 0.3 0.4 0.6 0.8 1.1 1.3 Normal saline 0.8 1.2 1.6 2.4 3.2 4.9 5.7
Total volume ml

1 1.5 2 3 4 6 7

<14

<50

10

Malaria in special situation

*Other type of plasmodium infection conistitute about 5-15% of cases presenting to health facility.
*In sudan P.ovale,P.malarie,P.vivax asexual infection are sensetive to chloroquine. *Primaquine should following the treatment of the asexual stage of P. vivax to clear the exoerythrocytic cycle.The dose for children is 0.25mg\kgbody weight for 14 days.

Malaria prophylaxis and Prevention

In Sudan the whole population is at risk to malaria but there special groups at higher risk to malaria infection: # Travelers from malaria free area(visitor). # sickle cell disease. # splenectomized individuals. # children on steroids. # Sudanese returning from non malarious area.

**For the above special groub the recommended prophylactic regimen is mefloquine.For the children the dose is 5mg\kg (one tab)every 7 days.starting one week before entering the area,once weekly while in the area, and once weekly for 4 weeks after leaving the area.not use in children below 3 month. **For who can,t take mefloquine another chemoprophylaxis is use(atovaquone-proguanil). The prophylactic dose is according to the wt of child.Not recommended in wt <11kg.